Operative Orthopaedics Stanmore Guide 2010
Operative Orthopaedics Stanmore Guide 2010
Operative Orthopaedics Stanmore Guide 2010
Edited by
Timothy Briggs MD MBBS (Hons) MCH (Orth) FRCS (Eng) FRCS (Ed) MD (Res)
Royal National Orthopaedic Hospital Trust, Stanmore, UK
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Tim Briggs, Jonathan Miles, Will Aston
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Contents
Contributors ix
Preface xi
Acknowledgements xiii
2 Tumours 6
William Aston and Timothy W R Briggs
17 Amputations 293
William Aston and Rob Pollock
Index 301
Contributors
William Aston BSc MBBS FRCS (Ed) (Tr & Orth) Mike Fox MBBS
Consultant Orthopaedic Surgeon, Royal National Consultant Orthopaedic Surgeon, Royal National
Orthopaedic Hospital Trust, Stanmore, UK Orthopaedic Hospital Trust, Stanmore, UK
Simon Clint BSc MBBS FRCS (Tr & Orth) Aresh Hashemi-Nejad FRCS FRCS (Orth)
Specialist Registrar, Royal National Orthopaedic Consultant Orthopaedic Surgeon and Clinical
Hospital Trust, Stanmore, UK Director, Royal National Orthopaedic Hospital Trust,
Stanmore, UK, and Honorary Senior Lecturer,
Michael Cooper BSc MBCHB FRCA University College London, London, UK
Department of Anaesthetics, Royal National
Russell Hawkins BSc MBBS MRCS (Eng) FRCS (Tr & Orth)
Orthopaedic Hospital Trust, Stanmore, UK
Specialist Registrar, Royal National Orthopaedic
Nicholas Cullen BSC MBBS FRCS (Tr & Orth) Hospital Trust, Stanmore, UK
Consultant Foot and Ankle Surgeon, The Royal
Deborah Higgs FRCS (Tr & Orth)
National Orthopaedic Hospital Trust, Stanmore, UK
Royal National Orthopaedic Hospital Trust, Stanmore,
Lee A David MBBS MRCS (Eng) FRCS (Tr & Orth) UK
Consultant in Trauma and Orthopaedic Surgery,
Max Horowitz MBBS
Maidstone and Tunbridge Wells NHS Trust,
Specialist Registrar, Royal National Orthopaedic
Maidstone, UK
Hospital Trust, Stanmore, UK
Gorav Datta MD FRCS (Tr & Orth) Hui Yun Vivian Ip MBCHB MRCP FRCA
Specialist Registrar, Royal National Orthopaedic Royal National Orthopaedic Hospital Trust,
Hospital Trust, Stanmore, UK Stanmore, UK
James Donaldson MBBS BSc MRCS Laurence James BSc MBBS MRCS (Eng) FRCS (Tr & Orth)
Specialist Registrar, Royal National Orthopaedic Foot and Ankle Fellow, Royal National Orthopaedic
Hospital Trust Rotation, Stanmore, UK Trust, Stanmore, UK
Mark Falworth FRCS (Eng) FRCS (Orth) Robert Jennings MBBS BSc MSC MFSEM (UK) FRCS ED
Consultant Shoulder Surgeon, Royal National (Tr & Orth)
Orthopaedic Hospital Trust, Stanmore, UK Royal National Orthopaedic Hospital Trust, Stanmore,
UK
x Contributors
Raman Kalyan MRCS MD FRCS (Tr & Orth) DNB ORTH Lauren Ovens MbChb MRCS
D ORTH (Eng) Specialist Registrar Plastic Surgeon, Royal Free
Clinical Lecturer/Specialist Registrar, Royal National Hospital, London, UK
Orthopaedic Hospital Trust, Stanmore, UK
Robert Pearl BSc FRCS (Tr & Orth)
Norbert Kang MBBS MD FRCS (Plast) Specialist Registrar Plastic Surgeon, Royal Free
Consultant Plastic and Hand Surgeon, Royal Free Hospital, London, UK
Hospital, London, UK Rob Pollock BSc FRCS (Tr & Orth)
Consultant Orthopaedic Surgeon, Royal National
Simon Lambert BSc FRCS FRCSEdOrth Orthopaedic Hospital Trust, Stanmore, UK
Consultant Orthopaedic Surgeon, The Shoulder and
Elbow Service, Royal National Orthopaedic Hospital, Matthew Shaw MBBS FRCS
Stanmore, UK Specialist Registrar, Royal National Orthopaedic
Hospital Trust, Stanmore, UK
Jonathan Miles MBCHB FRCS (Tr & Orth)
Royal National Orthopaedic Hospital Trust, Stanmore, Dishan Singh FRCS (Tr & Orth)
UK Consultant Foot and Ankle Surgeon, Royal National
Orthopaedic Hospital Trust, Stanmore, UK
Sean Molloy MRCS MSc (Orth Eng) FRCS (Orth) John Skinner MB BS FRCS (Orth)
Consultant Orthopaedic Spinal Surgeon, Royal Consultant Orthopaedic Surgeon and Honorary
National Orthopaedic Hospital Trust, Stanmore, UK Senior Lecturer, Royal National Orthopaedic Hospital
Trust, Stanmore, UK
Preface
Operative Orthopaedics: The Stanmore Guide aims This guide will serve junior trainees as they
to provide practical instruction in elective enter their surgical training and will acts as a
orthopaedic surgical procedures. Each chapter has revision tool for trainees sitting the FRCS (Tr &
been written by a consultant orthopaedic surgeon Orth) examination, which has evolved into a
and a trainee. It covers the list of procedures format emphasizing the importance of surgical
identified by the Specialist Advisory Committee procedures and the relevant anatomy.
as key in the field of orthopaedic surgery and The variety of equipment and instruments
presented as they are laid out in the training available to today’s orthopaedic surgeons is mind-
syllabus. boggling. The one essential tool for a surgeon in
It provides an explanation of orthopaedic training is an understanding of the basic
surgery from preoperative planning and consent, techniques, upon which all procedures depend.
through approaches and operative technique to The consistent and organized style of this book
postoperative care. Each procedure is described in will teach these techniques and enable its readers
a simple and consistent format to enable the to think logically and ‘keep a steady nerve’
reader to describe and carry out safe, evidence- in the potentially stressful situations of
based approaches and common operations. It independent operating and the FRCS (Tr & Orth)
contains key references and sample viva questions. examination.
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Acknowledgements
Thank you first and foremost to all of the trainees been vital to provide clear and well-illustrated
and consultants who have given generously of guidelines for the reader.
their time, knowledge and experiences to produce A huge thank you to our respective wives and
such informative writing in each chapter. families for putting up with us during this project.
Hodder Arnold have supported us admirably Final thanks go to Professor Briggs for having
from the first idea right through to final the idea of writing this book in the first place –
preparation of the book and their contribution has another professorial idea conceived in the bath!
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1
Anaesthesia in orthopaedic surgery
Hui Yin Vivian Ip and Michael Cooper
FASTING
INTRODUCTION
In elective surgery, standard local fasting times
The orthopaedic patient cohort is medically must be adhered to. A typical regimen is given in
diverse. Patients come from the extremes of Table 1.1. Food includes milk and fresh fruit
age, they may have complex causal pathology juices.
and, as they age, the patients develop multisystem
co-morbidity. The breadth of surgical inter-
Table 1.1 Fasting times
vention is great, ranging from procedures such as
arthroscopy causing minimal physiological
disturbance, to procedures that test, and often
Typical foods
Solid Water Breast Formula
surpass, the physiological reserve of an individual
food milk milk
patient. As such, the conduct of an individual
Fasting 6 hours 2 hours 4 hours 6 hours
anaesthetic is customized to the medical demands
time
of the patient, the requirements for the surgical
technique and the limitations of the institution in
which the surgery occurs. In trauma it is assumed that gastric emptying
stops at the time of injury. Fasting time is
calculated as time of intake to time of trauma. The
situation is further complicated by opiate
PREOPERATIVE ASSESSMENT AND analgesics that prolong gastric emptying and
render fasting times difficult to interpret. In these
GUIDELINES
circumstances the need to proceed with surgical
intervention may override fasting policy and
This is the process of assessing the relevance, surgery proceeds.
severity and treatment of the patient’s medical
pathologies. This allows referral for better AIRWAY
treatment (‘optimization’) and quantification of
the risk of adverse perioperative events, including A range of bedside tests exist that aim to predict
death, to be discussed and documented. Factors difficulties in maintaining an airway or intubating
specific to anaesthesia, such as a possible difficult an anaesthetized patient. Individual tests perform
airway, may also be considered. Central guidelines poorly and are not relevant here. Of particular
exist to inform the ordering of preoperative relevance in orthopaedic surgery are the
laboratory tests. challenges that a rigid cervical column or an
2 Anaesthesia in orthopaedic surgery
unstable cervical column may cause. The are especially useful for patients who are unable
challenge of rigidity may be a difficult airway and to perform exercise ECG due to
a difficult laryngoscopy. The challenge of an musculoskeletal disease or severe
unstable column is to prevent cord injury. Both cardiopulmonary disease. Perfusion defects of
are initially assessed with plain radiography. the myocardium under physiological stress
Specialized investigations to delineate pathology indicate coronary insufficiency.
include computed tomography (CT) and • Cardiopulmonary exercise testing – this is a
magnetic resonance imaging (MRI). dynamic test that predicts the patient’s
anaerobic threshold. As such it tests respiratory
CARDIOVASCULAR ASSESSMENT and cardiac reserve. It reflects other factors such
as motivation, mobility and nutrition. It can be
This is aimed at quantifying the ability of the used to predict the risk of surgery and obviate
cardiovascular pump to increase work to match the need for other tests such as angiography or
perioperative metabolic demands. It is an echocardiography.
assessment of reserve and of the risk of adverse • Coronary angiography – this is used to visualize
events such as an acute coronary syndrome. Key coronary arterial flow and disease. This is often
clinical markers are described below. the end point of coronary investigation and may
allow treatment by stenting and angioplasty at
Exercise tolerance the same time.
effective, safe and popular. Better pain scores transmission. However, red cells are vital to
and fewer side effects (nausea, vomiting, and oxygen delivery and haemostasis. The trigger will
sedation) are regularly received using this depend on the predicted continuing blood loss,
modality of opiate delivery compared with the patient’s co-morbidities and symptoms.
intermittent intramuscular dosing. Other routes Typically a haemoglobin concentration of 8 g/dL is
such as transdermal delivery are available. These taken as acceptable.
take a long time to reach a steady plasma
concentration and are similarly slow to decline DISPOSAL
when discontinued. This inflexibility makes them
difficult to use in the perioperative period. They High-dependency care may benefit many
are more suited to long-term use in chronic pain orthopaedic patients. Delivery of this will depend
syndromes. on local protocol and infrastructure. Clearly, those
at increased risk of organ failure or requiring a
higher level of nursing supervision should be
Local anaesthesia
placed in an appropriate environment.
Local anaesthetic techniques may be continued
into the postoperative period. These provide
RECOMMENDED REFERENCES
excellent analgesia with minimum side effects.
However, immobility may be a problem. Well-
conducted blocks in units used to managing these Fischer HBJ, Simanski CJP. A procedure specific
patients are very successful and do not need to and systematic review and consensus
delay mobilization. recommendations for analgesia after total hip
replacement. Anaesthesia 2005;60:1189–202.
OXYGEN Fischer HBJ, Simanski CJP, Sharp C, et al. A
procedure specific systematic review and
Oxygen therapy should be given to patients with consensus recommendations for postoperative
an epidural infusion, or PCA, which contains analgesia following total knee arthroplasty.
opiates. This supplemental oxygen maintains Anaesthesia 2008;63:1105–23.
alveolar oxygen tension longer if respiratory Fowler SJ, Symons J, Sabato S, et al. Epidural
depression and hypoventilation occurs. Supple- analgesia compared with peripheral nerve
mental oxygen used for the first 3 days post- blockade after major knee surgery: a systematic
operatively can also minimize the risk of review and meta analysis of randomized trials. Br
perioperative ischaemic events. Clearly, patients J Anaesth 2008;100:154–64.
with respiratory pathology (respiratory tract
infection, atelectasis, thromboembolism) will be
relatively hypoxic and oxygen therapy is an Viva questions
essential.
1. In patients with hypertension, how would you
FLUID MANAGEMENT determine whether elective surgery can
proceed?
The goal of intravenous fluid therapy is to
2. What are the contraindications to neuraxial
maintain normovolaemia. This allows adequate blockade?
cardiac output and, assuming a reasonable
haemoglobin concentration, tissue oxygen 3. Why is a respiratory tract infection a
delivery. Maintenance water and electrolytes need problem?
to be supplied and ongoing blood loss 4. Who should receive oxygen therapy in the
compensated for in the form of blood substitute, postoperative period?
or blood itself. Triggers for transfusion vary. Blood 5. When could an echocardiograph be the
is expensive, immunosuppressant, associated with preoperative investigation of choice?
worse outcome and a vehicle for disease
2
Tumours
William Aston and Timothy Briggs
Templating
The needle entry point and tract needs careful
thought and should be planned by the surgeon
performing the tumour resection, as the biopsy Figure 2.1 Jamshidi needle
Needle biopsy of bone 7
For tumours that have a large soft tissue pass directly to the site of the tumour and through
component or that have destroyed the cortex, a only the myofascial compartment in which the
Trucut or Temmo (preloaded) needle can be used. tumour is located, preferably through muscle and
These take a slice of tissue and come in 11 and 14 away from the neurovascular structures at risk. It
gauges. should aim to take a representative sample of the
tumour, which can be identified on pre-biopsy
Anaesthesia and positioning imaging. The needle is passed after a simple stab
incision in the skin, with a no. 15 blade.
Needle biopsy can be done under local, local with
sedation or general anaesthesia. For children, hard Deep dissection
lesions and lesions which may be difficult to
access, a general anaesthetic should be used. The needle is passed through the stab incision and
Positioning is dependent on the area to be directly to the area being biopsied, under
reached and if necessary the imaging modality radiological control if necessary.
being used.
Technical aspects of procedure
SURGICAL TECHNIQUE
Multiple core biopsies are needed, aiming to
Landmarks and incision minimize diversion from the tract. If unsure
whether representative tissue has been taken, a
The line of the biopsy should be sited in the line frozen section should be undertaken. In cases
of a possible future surgical incision, so that it can where preoperative imaging is atypical or where
be excised at the time of surgery (Fig. 2.2). It must infection is suspected, samples should also be sent
for microbiology.
The needle should not be passed through the
lesion into normal tissue. For lesions close to
joints, the needle must not pass through the
capsule and therefore potentially contaminate the
joint. It may be necessary to drill the bone prior to
needle insertion in sclerotic lesions. Careful
handling of the specimens is important so as not
to destroy the microarchitecture. Discussion with
the histopathologist will elucidate whether they
Deltopectoral
Biopsy wish to receive the specimen fresh or fixed in
approach
formalin.
Closure
Use Steri-Strips.
POSTOPERATIVE INSTRUCTIONS
• Neurovascular and routine observations.
• Local pressure in the case of vascular lesions.
RECOMMENDED REFERENCES
Figure 2.2 Position of biopsy for proximal humeral
tumour – in the line of the deltopectoral approach, but Saifuddin A, Mitchell R, Burnett S, et al.
slightly lateral so that the needle passes through the Ultrasound guided needle biopsy of primary bone
deltoid muscle and avoids the cephalic vein tumours. J Bone Joint Surg Br 2000;82:50–4.
8 Tumours
Stoker DJ, Cobb JP, Pringle JAS. Needle biopsy of SURGICAL TECHNIQUE
musculoskeletal lesions. A review of 208
procedures. J Bone Joint Surg Br 1991;37: Landmarks and incision
498–500.
The incision should be in the line of a possible
future operative approach so that the biopsy tract
can be resected with the specimen.
OPEN BIOPSY OF BONE
Dissection
PREOPERATIVE PLANNING Dependent on the location.
Closure
Templating
Routine.
The incision should be planned with the surgeon
and be made in the line of the surgical approach
that will be used to remove the tumour. POSTOPERATIVE INSTRUCTIONS
Thought should be given as to how to localize
the tumour, e.g. with image intensifier Neurovascular observations.
intraoperatively if necessary.
RECOMMENDED REFERENCES
Anaesthesia and positioning
Ashford RU, McCarthy SW, Scolyer RA, et al.
Regional/general anaesthesia and patient Surgical biopsy with intra-operative frozen
positioned to enable good access. section. An accurate and cost-effective method for
Exision of benign bone tumour 9
PREOPERATIVE PLANNING
Indications
EXCISION OF BENIGN BONE TUMOUR
Chronically infected or thickened bursae.
PREOPERATIVE PLANNING
Consent and risks
Common indications
Risks are dependent on the location of the bursa.
General risks, such as infection, apply as well as • Impending fracture, e.g. aneurysmal bone
stiffness of the surrounding soft tissues due to cyst
removal and postoperative scarring. • To prevent further bony destruction and/or
functional loss in aggressive lesions – e.g. giant
cell tumour
Templating • Mechanical symptoms – osteochondroma
• Pain – osteoid osteoma
Plan and approach depends on site. • Risk of malignant transformation.
SURGICAL TECHNIQUE
BONE CYST CURETTAGE ± BONE GRAFT
Landmarks and incision
PREOPERATIVE PLANNING
As per preoperative plan.
Indications
Dissection
• Risk of fracture or repeated fracture
The exposure is dependent on the anatomical • Failure of other methods of treatment, such as
location and whether the plan is to perform a steroid injection into the cyst.
curettage of the lesion (intralesional excision) or
to excise it (marginal excision) and reconstruct it. Contraindications
It is usually unwise to attempt tumour excision
and reconstruction through ‘minimally invasive’ If radiology is not classical of a bone cyst, then
approaches. histopathological diagnosis should be sought.
PREOPERATIVE PLANNING
Common indications
• Excision of an isolated primary tumour
• Excision of a primary tumour with metastatic
disease depending on life expectancy
• Excision of isolated metastases
• Excision of a fungating tumour for local control
• Excision of tumour recurrence.
Contraindications
• Poor life expectancy
• Co-morbidities
Figure 2.4 Screening the extent of the cavity to be • Malignancies treatable by chemotherapy alone
curetted such as lymphoma.
12 Tumours
Dissection
Dissection must enable removal of the tumour en
bloc with a layer of normal tissues surrounding it
to provide a wide margin. In some cases
neurovascular structures may be preserved and
therefore a marginal excision around these
structures is performed. Postoperatively, an
opinion regarding adjuvant therapy is obtained.
However, if cure is sought, and the neurovascular
structures are involved then they must be
Marginal Wide
Radical sacrificed. This may mean an amputation or
excision excision reconstruction of the vessels.
excision
The wound should be thoroughly washed with • Weightbearing and physiotherapy – depend on
water (as water is highly hypotonic, it may aid in procedure.
lysis of any spilled tumour cells) after removal of
the tumour. If any spillage of the tumour or RECOMMENDED REFERENCE
invasion of the capsule of the tumour has taken
place intraoperatively then after washing, new Enneking WF, Maale GE. The effect of
instruments, gloves and gowns should be used for inadvertent tumour contamination of wounds
reconstruction and/or closure. during the surgical resection of musculoskeletal
If it is found postoperatively on histological neoplasms. Cancer 1988;62:1251.
examination that an inadequate margin has been
taken then a repeat wide local excision should be RECOMMENDED REFERENCES (FOR
considered. WHOLE CHAPTER)
General information relating to all of the above
Closure topics can be found in:
Enneking WF. Musculoskeletal Tumour Surgery.
• Routine closure
New York: Churchill Livingstone, 1983.
• Drains to be placed in line of incision to
Malawer MM, Sugarbaker PH. Musculoskeletal
facilitate tract excision if re-excision is
Cancer Surgery Treatment of Sarcomas and Allied
necessary.
Diseases. Dordrecht: Kluwer Academic
POSTOPERATIVE CARE AND Publishers, 2001.
INSTRUCTIONS Sim FH, Frassica FJ, Frassica DA. Soft tissue
tumours: diagnosis, evaluation and management.
• Routine J Am Acad Orthop Surg 1994;2:202–11.
Viva questions
1. What do you know about the biopsy of a 11. What are the indications for excision of a
tumour? malignant bone tumour?
2. How would you perform a biopsy of a bony 12. How would you plan the excision of a
lesion? malignant bone tumour?
3. How would you perform a biopsy of a soft 13. What are the principles involved in the excision
tissue lesion? of a malignant bone tumour?
4. How would you choose between a needle 14. What is the difference between an open biopsy
biopsy and an open biopsy? and an excision biopsy?
15. What does a marginal resection mean?
5. What must be avoided during biopsy?
16. What is the difference between a wide and a
6. How would you excise a bursa?
radical resection?
7. How would you make a cortical window in 17. How would you ensure that you have an
bone? adequate biopsy?
8. How would you treat a benign bone cyst? 18. What do you understand by the term limb
9. What are the indications for excision of a salvage?
benign bone tumour? 19. Why might it not be possible to salvage a limb?
10. What considerations have to be taken into 20. Where and by whom should a biopsy be carried
account when excising a benign bone tumour? out?
3
Surgery of the cervical spine
Raman Kalyan and David J Harrison
Anterior approach to cervical spine (C3–T1) 14 Halo vest fixation of the cervical spine 21
Posterior approach to cervical spine (C2–C7) 18 Viva questions 25
Posterior approach to upper cervical spine (C1–C2) 20
• Dysphagia: 50 per cent in short term; 10 per An image intensifier should be available from the
cent long term (more common in multilevel start of the procedure. If an operative microscope
surgery, longer retraction time, older patients). is to be used it should be pre-booked. Some prefer
This complication can be reduce by keeping to use magnification loupes, along with headlights
retraction time to a minimum, using smooth for improved illumination of the operative field.
contour retractors, lower profile plate, good All radiological investigations should be
tissue handling and haemostasis. available. Check/pre-order the specific implants
• Recurrent laryngeal nerve injury: 0.2 per cent; it and instrumentation.
produces paralysis of one side of the vocal cord, If iliac bone crest graft is required, then the side
and leads to hoarseness of the voice, airway and draping need to be pre-planned; a tri-cortical
problems and aspiration. More common in the graft is best. In high-risk cases, the spinal cord
right-sided approach. The reason for its integrity is monitored intraoperatively using
vulnerability on the right side is because of its evoked potentials (somatosensory or motor) and
course, as it crosses from lateral towards the this needs to be organized.
trachea in the midline, in the lower part of the
neck. Some consider it to occur due to the dual
ANAESTHESIA AND POSITIONING
compression of the nerve from the self-retaining
The operation is performed under general
deep retractor on the lateral aspect and medially
anaesthesia. The head end of the patient is
by the cuff of the endotracheal tube within the
positioned opposite to the anaesthetist; therefore,
trachea. This can be avoided by relaxing the
long tubing is needed which requires to be safely
retractor often and deflating and reinflating the
placed and well secured. The outer end of the
cuff after application of the retractor
endotracheal tube is positioned and fixed away
• Other neurological injuries: superior laryngeal
from the side of the incision. Prophylactic
nerve, hypoglossal nerve, sympathetic nerve and
antibiotics are given as per protocol.
stellate ganglion
Place the patient in a supine position on the
• Spinal cord injury
operating table with or without Mayfield skull
• Vascular injury: inferior thyroid artery, common
clamp attachment. Head ring and adhesive tape
carotid artery, vertebral artery, internal jugular
are used to position the head securely if the
vein
Mayfield clamp is not used. The Mayfield skull
• Haematoma
clamp attachment provides a three-point rigid
• Visceral injury: oesophagus, trachea
cranial fixation and allows greater flexibility in
• Infection: 0.5 per cent
positioning of the cervical spine and better
• Cerebrospinal fluid (CSF) leak and fistula: 0.1 per
visualization during imaging. It is particularly
cent
useful in surgery for cervical spine fracture. It
• Death: 0.1 per cent
enables better control of cervical spine position
and allows change in position and manipulation
during surgical procedure.
A rolled up pad or saline bag or sandbag is
Risks for fusion/stabilization placed between the scapulae to enable slight
extension of the cervical spine as desired. The
• Bone graft donor site morbidity head is minimally rotated to the opposite side of
• Non-union/pseudarthrosis: 4–20 per cent in the planned approach to enable better access. The
single level fusion, 25–50 per cent in multilevel head end of the table is tilted up to minimize
fusion venous bleeding. The foot end of the bed may
• Implant pull out/failure need levelling to prevent migration of the patient
• Anterior graft migration down the bed. To enable adequate visualization of
the lower cervical spine an image intensifier is
16 Surgery of the cervical spine
Deep cervical
fascia
Carotid
sheath Sternocleidomastoid
muscle
handling needs to be kept minimal and care shoulders down, and the position of the image
taken not to plunge instruments into the intensifier and microscope is checked. The head
interlaminar space. The laminae can be end of the table is tilted upwards to minimize
surprisingly thin and fragile venous bleeding.
• Vertebral artery injury: (rare). Vertebral artery is
at risk when the exposure extends over the
transverse process and in surgery involving C1 SURGICAL TECHNIQUE
and C2. Injury bilaterally endangers the blood
supply to the hindbrain Landmarks
• General morbidity and mortality are shown to be
Identification of the level is important to avoid
increased in patients of older age and those with
unnecessary dissection of the wrong levels. The
myelopathy
external occipital protuberance and the longer
spinous processes of C2, C7 and T1 vertebrae are
easily palpable landmarks to guide the location of
Operative planning the incision. An image intensifier can also be used
to verify the level as needed.
An image intensifier should be available at the
start of the procedure, for example to check for Incision
spine alignment during positioning in patients
who have instability of the cervical spine. The A midline straight incision centring over the
image intensifier is also used perioperatively to exposure required. The skin in this area is vascular
identify level, check spinal alignment, and check and thick and adrenaline can be injected to reduce
implant, screw and graft position. For other bleeding.
considerations at this stage, see ‘Anterior approach
to the cervical spine’ (p. 14). Superficial dissection
Anaesthesia and positioning
Structures at risk
The operation is performed under general
anaesthesia. The patient is placed in the prone Segmental vessels and venous plexi (bleeding is
position on the operating table. The head end of much worse if dissection strays from the midline or
the patient is positioned at the opposite side to into muscle. Lateral extension of the dissection
the anaesthetist. The long anaesthetic tubing is beyond the facet joint risks bleeding from the
secured safely. segmental vessels).
The head is positioned in a special head ring
or brace, or held by a Mayfield skull clamp The fascia is incised at the midline. Retractors and
attachment, which provides three-point rigid palpation are used to keep dissection in the
cranial fixation, allows greater flexibility in midline. The nuchal ligament is split in the
positioning and better visualization during midline and the spinous process is reached. The
imaging. The eyes should be protected spinous processes of C3, C4, C5 and C6 are
appropriately during prone positioning. During normally bifid.
exposure the neck is positioned in slight Using Cobb elevators and diathermy, further
flexion, to allow easier dissection and avoid skin dissection is carried out in the subperiosteal plane
creasing. reflecting the paracervical muscles off the spinous
The spinal stability needs to be taken into process and the lamina, either bilaterally or
account and the spinal alignment to be checked unilaterally as required. The extent of lateral
with imaging if necessary. As with the anterior extension depends on the procedure planned, e.g.
approach, broad strips (10 or 15 cm [4 or 6 need to expose the facet joint or transverse
inches]) of adhesive tape are used to pull the process.
20 Surgery of the cervical spine
Spinous Fascia
process
Trapezius
Paracervical
muscles
Lamina
Posterior
Superior
tubercle
articular
process
Spinal
nerve
PREOPERATIVE PLANNING
SURGICAL TECHNIQUE
Indications
Landmarks
• Cervical spine trauma (temporary or definite
• External occipital protuberance in the posterior
stabilization), e.g. odontoid and upper cervical
aspect of the skull in the midline (midpoint of
spine fracture, fracture of the occipital
the superior nuchal line)
condyles
• The spinous process of C2 vertebra (the longest
• External stabilization following surgery as a
in the upper cervical spine).
primary stabilizer or as an adjuvant, e.g. after
An image intensifier can also be used to verify the osteotomy for ankylosing spondylitis
level as needed. • Instability due to infection or tumour
22 Surgery of the cervical spine
SURGICAL TECHNIQUE
performed with a scalpel. Now the secured halo An image intensifier may be used to check the
ring can be used to control and position the cervical spine position and to enable correction
cervical spine for further procedures. under image guidance. All of the fixations are
retightened when a satisfactory position is
Vest application achieved.
RECOMMENDED REFERENCES
Viva questions
1. How do you position a patient for anterior 7. What are the structures at risk during a
cervical spine surgery? posterior approach to the upper cervical spine
and how are they avoided?
2. Describe the steps of the anterior cervical
approach and the reasons behind them. 8. How do you apply a halo to stabilize the
cervical spine?
3. What are the structures at risk in anterior
cervical surgery and how are they avoided? 9. What complications occur in halo stabilization
of the cervical spine?
4. Describe the radiological signs indicating
cervical spine instability. 10. How is a halo vest looked after following
application?
5. Describe how you will position a patient for
the posterior approach to the cervical spine.
6. What are the structures at risk during a
posterior approach to the lower cervical spine
and how can they be avoided?
4
Surgery of the thoracolumbar spine
Matthew Shaw and Sean Molloy
Closure
On closure, a chest drain is inserted and the chest
closed in layers. First, 1 Vicryl is applied to the
pleura and transverse thoracis and then each
individual layer is sutured. Second, 2-0 Vicryl is
placed into the fat layer and a subcuticular layer
applied to the skin to give the best cosmetic
result.
Figure 4.2 Thoracic vertebrectomy with posterior stabilization for a solitary metastasis
Figure 4.3 A fracture dislocation of the thoracic spine stabilized with posterior thoracic rods and screws
of the sacrum or C2 are not there to refer to. It is pressure on the patient’s axilla, which could cause
important to check the number of ribs a patient a nerve palsy. Padding is used under the patient’s
has on plain X-ray, as these can be used to mark elbows to avoid an ulnar nerve palsy. There must
the skin using fluoroscopy prior to incision. be no pressure on the eyes and, if possible, the
table should be slightly head up to decrease
Anaesthesia and positioning central venous pressure.
prominens can also be used as a reference to authors preferred method is one of piecemeal
centre the incision. In general, either the ribs or removal of the spinous process followed by
the spinous processes can be counted to obtain removing the lamina using an up-cutting punch.
the correct level. The pars should be left intact, with at least 5 mm
remaining laterally if instrumentation is not
Incision undertaken or this will cause destabilization of the
spine.
An incision is made in the midline, centred on the
appropriate vertebra. Note the pedicle entry point Closure
will be above the spinous process of the vertebra
counted and therefore the incision should allow Closure is in layers. A drain may or may not be
for this. inserted.
• Neurological conditions where progression is • Imbalance can occur in either the sagittal or
certain and respiratory function affected coronal planes
• Cosmesis. • Back pain (fortunately uncommon)
• Injury to the thoracic duct
Contraindications • Major vessel injury
• Blindness: 0.028–0.2 per cent
• Minor curves For posterior procedures:
• When the patient’s expectations do not match • All of the above complications apply to posterior
the surgeon’s approaches to surgery, however, neurological
• Poor respiratory function likely to lead to complications are probably slightly more
prolonged ventilation common in the posterior approach and obviously
• Spinal dysraphism, leading to a high rate of there is no risk of damage to the thoracic duct
neurological complications (relative). • Posterior approaches involve a significant scar,
which sometimes stretches from T2 to the pelvis
Choice of approach • Blood loss with this approach can be
considerable if not controlled adequately
• There is an increasing trend towards posterior- • Wound infection rates are probably slightly
only surgery. However, much depends on the higher with this approach
characteristics of the curve and on the surgeon’s
training and preference
• Thorough discectomy is only possible with an
anterior approach and thus very stiff curves Operative planning
may benefit from anterior release prior to
posterior surgery. Scoliosis surgery is a major undertaking which
• Thoracolumbar/lumbar curves are often treated should be performed in specialist centres. This
with anterior instrumentation, especially if chapter cannot cover every condition related to
there is no thoracic curve. scoliosis and their management but aims to give
• Posterior instrumentation allows fixation to the some general guidelines and advice to the
pelvis – an advantage in long fusions in the orthopaedic trainee.
elderly and in non-walking patients with Scoliosis is a diverse condition being mainly
neuromuscular-type curves. divided into degenerative, idiopathic, congenital
and neurological causes. Planning for these groups
will obviously be different but there are some
Consent and risks general principles:
Complications will depend on the approach. • All patients should be seen by a specialist
Anterior approach for idiopathic scoliosis: experienced in the treatment of scoliosis. All
• Mortality: 0.03 per cent patients should have a full history and
• Respiratory dysfunction/chest infection examination including birth and family history
• Neurological deficit: complete 0.03%; and any other medical problems likely relating
incomplete 1.5 per cent to their scoliosis.
• Non-union needing metalwork revision: 5 per • All patients should initially have
cent anteroposterior and lateral films of the whole
• Failure to achieve complete correction with spine. This will help in the overall planning of
residual curve or rotation surgery and assess spinal balance. If surgery may
• Damage to sympathetic chain leading to be indicated, the patient should be counselled
neurovascular change in the leg with regard to the risks involved and a whole
• Infection: 1–2 per cent spine MRI performed. This test, in the authors’
• Inequality of spinal balance and uneven shoulder view, is a mandatory requirement prior to
height surgery to exclude abnormalities of the spinal
column which could lead to an increase in
32 Surgery of the thoracolumbar spine
neurological complications. These include access to the discs that are to be removed. An
syrinx, cord tethering and Chiari malformations indwelling urinary catheter should be placed pre
of the brainstem. operatively.
• Following a (normal) MRI scan, patients are Patients receive a general anaesthetic. Hypo-
again counselled with regard to the risks and tension during anaesthesia is advantageous as this
benefits of surgery. A multidisciplinary team is may decrease blood loss. A double lumen endo-
needed, especially in the neurological scoliosis tracheal tube is helpful but not always necessary.
group.
• Patients need to be medically assessed if they Posterior procedure
have co-morbidities. For posterior procedures, the patient is laid prone,
• Paediatric review is important and social issues often on a Montreal mattress. This mattress has a
need to be resolved before surgery, as do the central cut-out that allows the abdomen to hang
issues of care following the procedure. free. This decreases the epidural venous pressure
Recovery is often lengthy in these patients. and the intraoperative bleeding. Arms should be
• Lung function tests are useful as well as a chest placed with the shoulders no more than 90°
X-ray and electrocardiogram (ECG). abducted and the elbows should be bent to no
Anaesthetic involvement is required early to more than 90°.
optimize the patient preoperatively. Gel pads should be used to pad the medial
• Bending scoliosis films should be performed epicondyles of the elbows to prevent ulnar nerve
prior to surgery. The purpose of this injury. The patient’s position should be slightly
investigation is to assess the flexibility of the head up to decrease venous pressure around the
curve which will in turn help the surgeon head and there should be no pressure around the
decide which levels need to be fused. Curves eyes. Cut-out foam or gel head supports are useful
are tremendously variable in their shapes as in controlling the head while avoiding pressure on
well as their flexibility. This is dependent on the the eyes.
patients’ underlying condition as well as the age Pillows should be placed underneath the
of the curve. patient’s legs with the knees slightly bent. In all
• Cord monitoring should be used during the spinal procedures, mechanical deep vein
procedure and an intensive care bed should be thrombosis (DVT) prophylaxis should be
booked prior to the procedure. considered.
example, if T9 needed to be instrumented and this entering the pleural cavity, the costal cartilage is
was the most superior level, the incision should be incised and the abdominal musculature divided
made through the bed of the seventh rib (Fig. inferomedially to allow exposure of the lumbar
4.5). levels. Care must be taken to avoid damage to the
The authors find it useful to use a marking pen peritoneum. The retroperitoneal fat is entered
and to mark the spinous processes of the deep to the costal cartilage, and the peritoneum
thoracolumbar spine. The incision is then marked then reflected anteriorly with careful finger
inside the extremes of the curve. dissection and the use of gauze swabs as necessary.
Dissection is carried down to the spine, anterior to
Approach the psoas muscle. The diaphragm is divided with
An incision is made in line with the proposed rib. electrocautery, leaving a peripheral cuff of around
Skin, fat and muscle are incised in line with the 2 cm of diaphragm to repair to later. Marking
rib. Haemostasis is obtained and self-retainers are sutures may be inserted to help the repair later.
placed. The periosteum is split on the rib and The great vessels and viscera are carefully
retracted off the rib. The rib is circumferentially reflected anteriorly and protected with blunt
cleared of periosteum and followed posteriorly as retractors throughout the procedure.
far back as possible. Anteriorly, the rib is exposed
to the costochondral junction, and then cut and Procedure
removed. The underlying pleura is exposed and
Once the spine is exposed, individual segmental
carefully incised, opening the chest and exposing
vessels can be tied, cauterized or preserved. Disc
the lung. Wet chest packs can be used to retract
material is then removed piecemeal until the
the lung superiorly. The posterior pleura is then
posterior longitudinal ligament is seen.
visible and this is incised taking care not to
Sympathetic nerves should be preserved if
damage the underlying segmental vessels.
possible.
If the planned release or instrumentation will
It is important to appreciate the rotation in the
cross the thoracolumbar junction, the diaphragm
spinal column as this considerably alters the
will need to be taken down. Either before or after
normal anatomy and whereabouts of the spinal
canal. Cartilaginous endplates are removed using a
Cobb, osteotome or curette. Ideally, bony
endplates should not be breached as this markedly
increases blood loss.
Pleura over esophagus When performing an anterior release or
Pleura over instrumenting the spine anteriorly, the removal of
azygos vein disc material provides an excellent fusion bed.
The removed rib can be broken into pieces and
used as autograft. When instrumenting the spine it
Pleura over Pleura over
is important to understand the rotation of the
intercostal medial end curve and the relationship of the vertebral body to
vein of rib the spinal canal. In the thoracic spine rib heads are
a good guide to the screw insertion point and give
Incision in
pleura Pleura over the posterior margin at which the screw can be
paravertebral inserted. Following disc removal it is possible to
Intercostal ganglion guide screws in parallel with the endplates of the
muscle
External suface of vertebra being instrumented.
retracted rib
In correcting scoliosis it is important to achieve
a ‘cadence’ of screw insertion with the apical screw
being most posterior. This will assist in the
Figure 4.5 The selection of rib level in anterior scoliosis derotation of the spine. Bicortical fixation is
surgery beneficial and aids stability. Following screw
34 Surgery of the thoracolumbar spine
insertion a rod is applied. The screw and rod are spinous process around the neck and this can
applied to the convexity of the curve and therefore often be palpated. It is possible to count down
compression in between individual screws aids from this level to identify the most superior
reduction (Fig. 4.6). Following reduction, the vertebra that will be instrumented. Alternatively,
screw heads are given a final tighten. an X-ray can be used or a shorter incision made
and the ribs identified intraoperatively and
Closure counted upwards from T12.
The posterior pleura may be left open or closed
depending on the surgeon’s preference. The chest Incision
wall is closed in layers and a chest drain inserted
and sutured in. An incision is made to the required level as
previously described.
Posterior procedure
Dissection
Landmarks The subcutaneous fat and fascia are incised. The
It is vital to identify the appropriate levels in the spinous processes are identified and subperiosteal
thoracic spine. C7 is usually the most prominent dissection is performed. This is extremely
important with such large wounds, as dissection in trajectory is more horizontal in the curve
the wrong plane will lead to excessive bleeding. concavity and more vertical in the curve convexity
Gauze is used to pack the wounds on each side because of the associated rotation of the spine in
to limit blood loss. Gel foam combined with scoliosis. Spinal cord monitoring is mandatory
adrenaline can also help in this regard. Dissection throughout this procedure.
is carried out laterally in the lumbar spine to the Screws need not be inserted at every level.
transverse processes in order that pedicle screw Screw sizes are usually between 5 mm and 7 mm
entry points can be identified. In the thoracic in diameter and vary in length from around 25
spine, the dissection is carried laterally to identify mm to 50 mm. Every surgeon will have a
the transverse processes and the lateral edges of particular construct which he or she uses. In the
the facet joints. upper thoracic spine, pedicle screws can be used
alone or in combination with lamina, pedicle or
Procedure transverse process hooks.
Pedicle screw fixation in scoliosis is challenging. Before rod placement, de-cortication is
Rotation makes for difficult pedicle screw extremely important. Facets are destroyed and
placement. In the sagittal plane, screw angles can lamina de-corticated in order for fusion to occur.
be judged from a 90° line to the lamina above and Rods are then inserted. There are several ways to
below the level being instrumented. In the reduce the spine, and the authors’ preferred
transverse plane, screw angles may be judged from method is by derotation of the construct
a Kocher placed on the spinous process. This sequentially from superior to inferior.
technique gives a guide to the amount of rotation Pedicle screw fixation is a very powerful
in a particular segment. In general, the screw technique for reducing spinal deformity (Fig. 4.7).
Cross-links can be added to the construct to have a CT scan to identify the position of the
increase strength and load sharing. Many metalwork.
alternatives exist for bone grafting with some
surgeons preferring local bone graft alone whereas RECOMMENDED REFERENCES
others use a variety of bone graft substitutes/
allograft and types of bone morphogenic protein Baig MN. Vision loss after spine surgery: review of
(not to be used in the growing spine). the literature and recommendations. Neurosurg
Focus 2007;23:E15.
Closure Weiss HR, Goodall D. Rate of complications in
The spine is closed in layers with a watertight scoliosis surgery – a systematic review of the Pub
closure being of great importance. Med literature. Scoliosis 2008;3:9.
ideal solution for back pain and most procedures • An MRI scan is ordered preoperatively. Blood
with or without fusion are performed for leg tests may be indicated preoperatively to
symptoms. Fusion is needed in cases of instability exclude infection where discitis is suspected.
or where decompression is likely to cause Scans should be reviewed with the patient. All
instability in the long term. forms of conservative treatment must be
exhausted before spinal fusion is considered.
Indications The patient’s expectations must be managed
in order to achieve the best result. It is sensible
• Spondylolisthesis for the surgeon to meet the patient several
• Lumbar spinal trauma times pre operatively.
• Spinal stenosis associated with instability or • An anaesthetic assessment may be needed
degenerative disc disease preoperatively. A cell saver should be
• Degenerative deformities. considered for extensive fusions and if
deformity correction is to be performed, spinal
Contraindications cord monitoring should be undertaken
L4 Procedure
S2 Structures at risk
• Dura
• Nerve root
Figure 4.9 Anatomical levels in the lumbar spine
Once dissection is complete, it is important to use
X-ray guidance to mark the correct level. This can
Incision be done by means of a marker on a spinous
process or pedicle.
Following adequate positioning of the patient and Once the level is identified, screws can be
level identification, a midline longitudinal incision inserted as necessary. Screws are inserted at the
is made. confluence of the pars, transverse process and
facet (see Fig. 4.11, p. 36). Following screw
Dissection insertion, rods can be inserted and distraction or
compression applied as needed. Following
Subcutaneous tissues, fat and fascia are incised in instrumentation, decompression can be
line with the skin. Haemostasis is obtained. A undertaken if required.
Cobb retractor is used to put the paraspinal There are many ways of performing this
musculature under tension. Diathermy is then procedure, and the authors’ preference is to use a
used to resect the musculature off the posterior burr and an osteotome to remove the lamina.
vertebra. On an initial first pass the muscles are Nerve roots are then explored and an
dissected from the spinous processes and laminae undercutting facetectomy can be performed using
onto the medial border of the facets. It is an osteotome or up-cutting punch. It is important
important not to damage the facet joints and that nerves are decompressed both in the lateral
while performing a fusion, the superior facet joint recesses and out through the foramen. The
in the fusion should be protected and not foramen can be enlarged by applying distraction
violated. through the screw construct.
The wound is packed on each side and deeper Dural breach occurs in up to 5 per cent of
retractors inserted. When performing an instru- procedures and can be repaired using 5-0 Prolene
mented fusion it is important that the pedicle suture by means of an interrupted or continuous
entry points are clearly seen. In the lumbar spine technique. Other options include blood, fascia or
this involves the visualization of the pars, and fat patches, dural ‘glues’ or membranes designed
the junction of the transverse process and the to seal dural leaks, such as DuraGen.
facet. The wound is closed in layers. If a dural leak has
40 Surgery of the thoracolumbar spine
Consent and risks The authors prefer to mark the level pre- and
intraoperatively. A needle is placed in the
• Nerve root injury: 1 per cent prepared skin at the point which it is estimated
that the target level sits. A cross-table lateral X-ray
Lumbar disc surgery 41
is taken. The needle is adjusted and inserted onto level and therefore cross-table fluoroscopy is used
the spinous process of the correct level. An with a McDonald elevator in the canal.
estimate of disc level can be taken from the An interlaminar window is then developed. In
surface landmarks (see Fig. 4.9, p. 39). some cases very little bone needs to be removed in
this process. In arthritic spines the dissection can
Incision be difficult and a substantial amount of bone is
resected. It is important not to remove more than
The level involved is marked with a needle, and one-third of the facet as this may cause instability
the skin incision is centred on the marker. warranting further procedures.
The dura is carefully exposed and, as the
Approach window is expanded, the nerve root is found and
protected. Before the disc material is removed, it
The fat and fascia are incised in line with the skin. is essential that the nerve root is identified.
Diathermy is then used to dissect the musculature Sometimes the disc lies below the posterior
off the posterior elements of the spine.
Haemostasis is obtained. The soft tissue is swept
laterally using a Cobb elevator. The outer aspects
of the facet joints are identified.
Ascending
It is important for the operating surgeon to be articular
able to identify the important landmarks as well as process
the correct level. The lamina of the vertebra above
the disc is identified and the inferior edge
delineated. The ligamentum flavum should be Descending
articular
identified and then incised. A McDonald elevator process of
can be used to protect the underlying dura. If it is Cauda
proximal
equina
difficult to expose the dura, or there is a very vertebra
narrow interlaminar window, it is sometimes
helpful to start removing the inferior border of the Posterior
Spinal nerve longitudinal
superior lamina. The ligamentum inserts into the
ligament
underside of the lamina and therefore once the Herniated disc
(with overlying
attachment has been released the ligamentum veins)
opens like a ‘curtain’. Once the canal has been
opened it is important to again check the operative Figure 4.11 The operative view in lumbar discectomy
42 Surgery of the thoracolumbar spine
Contraindications
Anaesthesia and positioning • Coagulopathy
• Inability to tolerate injections or have
Patients are placed prone. The procedure can be anaesthetic/sedation.
performed under local anaesthesia, sedation or
general anaesthesia. Consent and risks
• Failure of treatment/short-lived effect (high risk)
• Infection (uncommon)
SURGICAL TECHNIQUE
The authors’ preferred method is to perform facet All patients should have at least a plain X-ray
blocks under CT control with an experienced prior to the procedure. In reality most patients
radiologist. Without this facility, blocks can be have an MRI scan before injection. Nerve root
performed with fluoroscopy in theatre. The angle blocks can be instigated on a clinical basis alone if
of the C-arm needs to be adjusted in order to there is delay in obtaining an MRI.
allow for the obliquity of the facets in the lumbar
spine. Needles can be placed within the facet joint Anaesthesia and positioning
and checked by means of insertion of Omnipaque
dye. The authors advocate performing up to three Patients are placed prone. The procedure can be
bilateral levels in one sitting; 2 mL of local performed under local anaesthesia, sedation or
anaesthetic and steroid combined are introduced general anaesthesia.
into the facet joints.
SURGICAL TECHNIQUE
Viva questions
1. Describe the relevant surgical landmarks when 10. Which nerve runs in the lateral recess at the
planning an anterior approach to the T10 L5/S1 level?
vertebral body.
11. Describe your intraoperative and postoperative
2. What are the indications for performing an management of a dural tear.
anterior approach to the spine?
12. What might be the presentation and
3. Describe where the segmental blood supply of management of an acute epidural haematoma?
the vertebral body lies in relation to the disc.
13. Describe the approach for a lumbar discectomy.
4. At what level of the thoracic spine does the
14. What nerve root would be compressed by an
inferior border of the scapula lie when the
L4/5 far lateral disc?
arms are by the sides? Where, in relation to the
spinous process, does the corresponding pedicle 15. An L4/5 left-sided paracentral disc protrusion
of the same vertebra lie? will impinge on which nerve root?
5. Describe what steps you would take to 16. What is the incidence of nerve root injury with
minimize wrong level surgery in the thoracic a discectomy?
spine.
17. Describe the orientation of the facet joints at
6. What role do chest drains have in thoracic different levels of the spine.
spinal surgery?
18. Following temporary success of facet blocks,
7. What factors are involved in selecting patients which other radiological procedure can be
for scoliosis surgery? performed with potential for longer-lasting
benefit?
8. Give a brief account of the preoperative
management of a patient due to undergo 19. Which nerve root leaves the spinal canal via
scoliosis surgery. the L4/5 foramen
9. Describe the positioning and the peripheral
nerves at risk from prone positioning of a
patient.
5
Surgery of the peripheral nerve
Gorav Datta, Max Horowitz and Mike Fox
Operative planning
CARPAL TUNNEL DECOMPRESSION
History and clinical examination remain the
PREOPERATIVE PLANNING mainstay of diagnosis. It is essential to examine the
entire limb as well as the cervical spine to exclude
Indications a ‘double-crush’ lesion. Nerve conduction studies
are useful and should be available on the day of
• Median nerve compression neuropathy at the surgery. They are considered essential in cases of
wrist recurrent carpal tunnel syndrome and complex
• As part of a fasciotomy for compartment upper limb lesions. Prolonged sensory latency is
syndrome/decompression after distal radial the earliest and most reliable nerve conduction
fracture abnormality. Magnetic resonance imaging (MRI)
• Drainage of sepsis. is rarely indicated, unless there is clinical evidence
of a space-occupying lesion causing the
Contraindications symptoms. Conventional radiography is not
generally indicated. Consideration should be given
• Active overlying skin infection
to extraneous causes such as diabetes mellitus,
• Uncertainty over diagnosis – may warrant
rheumatoid and other arthritides, amyloidosis and
further investigation before proceeding.
thyroid dysfunction; where appropriate these may
also require investigation prior to operation.
Consent and risks
• Nerve injury: median nerve injury <1 per cent; Anaesthesia and positioning
palmar cutaneous nerve injury <1 per cent
The procedure may be carried out under local,
• Radial artery injury: <1 per cent
regional or general anaesthesia. Most primary
• Failure to relieve symptoms: 1–10 per cent; the
decompressions are performed under local
incidence is highest in heavy/repetitive manual
anaesthesia. A local anaesthetic consisting of 1 per
workers
cent lidocaine and 0.5 per cent bupivacaine in a
• Pillar pain: quoted at up to 10 per cent, this is
1:1 mixture is infiltrated into the wound prior to
tenderness around the site of ligament release
surgical draping. General anaesthesia is usually
• Scar tenderness: the incidence is reduced by
reserved for revision procedures.
massage in the postoperative period
The patient is positioned supine on an
• Complex regional pain syndrome (rare)
operating table and the arm is positioned on an
• Infection
arm table in supination, with a padded lead hand
46 Surgery of the peripheral nerve
used to maintain finger extension. A tourniquet is ensures that proximal extension avoids the palmar
inflated to 250 mmHg. In obese patients, a cutaneous branch of the median nerve. The extent
forearm tourniquet is recommended. is from the distal volar wrist up to a few
millimetres proximal to the superficial palmar
SURGICAL TECHNIQUE arch. In revision surgery, the proximal extent is
increased: this is curved to run along the ulnar side
Landmarks of the palmaris longus tendon (Fig. 5.2). This
avoids crossing the wrist joint crease at a right
The tendon of palmaris longus (absent in about 10 angle and, once again, minimizes any damage to
per cent) is easily seen and palpated by opposing the palmar cutaneous branch of the median nerve.
the thumb and little finger and then flexing the
wrist to around 30°. The distal end of the tendon
Motor branch
bisects the anterior surface of the carpal tunnel.
of medial nerve Palmar cutaneous
Other useful landmarks include the thenar skin branch of median
crease (running at the base of the thenar nerve
eminence) and the transverse skin crease of the
Palmaris
wrist joint (running parallel to the joint line). The longus
transverse wrist crease marks the proximal border
of the flexor retinaculum. If the thumb is
outstretched to 90° a parallel line drawn across Median
the palm in line with its distal border represents nerve
the surface marking of the superficial palmar arch:
this is known as Kaplan’s cardinal line (Fig. 5.1).
Figure 5.2 Extended incision for revision/complex carpal
tunnel decompression
Incision
The incision runs a few millimetres to the ulnar
side of the thenar skin crease, in the line of the
Dissection
long axis of the ring finger. This ensures that any
scarring is well away from the median nerve and
Structures at risk
• Palmar cutaneous branch of the median nerve is
at risk if the skin incision is angled to the radial
side of the forearm
• Deep motor branch of the median nerve (due to
variation in its course) – staying on the ulnar
PCN R
side of the median nerve minimizes the risk of
FRC damaging the structure
M • Superficial palmar arch
PL
U K
• Median nerve
H
Extensile measures
These are generally not necessary for standard
Figure 5.3 Release of the flexor retinaculum carpal tunnel surgery and are reserved for specific
indications.
insertion of palmaris longus into the flexor Proximal
retinaculum. If it is in the way, it can be retracted
The approach may be extended proximally to
to the radial side: this exposes the median nerve.
expose the median nerve in the forearm. This may
Careful dissection through the flexor retinaculum
be required in cases of fracture fixation with
is recommended until the nerve is visualized. A
concomitant carpal tunnel decompression.
McDonald tissue dissector is passed between the
Extension is gained between the tendons of flexor
plane of the flexor retinaculum and the median
carpi radialis and palmaris longus. The nerve lies
nerve. The dissector must be used with caution
on the deep surface of flexor digitorum
and should elevate the retinaculum and not press
superficialis in the forearm. The median nerve is
down on the nerve. The flexor retinaculum is
retracted to the ulnar side and pronator quadratus
incised with a scalpel, cutting down onto the
incised to access the distal radius.
McDonald tissue dissector, which lies over the
nerve and protects it (Fig. 5.3). Distal
The nerve is released from proximal to distal. In
The incision may be extended distally with a
revision surgery the nerve should be dissected out
zigzag incision (Brunner incision) to access any
proximal to the wrist crease. The perivascular fat
digit, providing a complete palmar exposure. This
pad is the distal border of the flexor retinaculum.
is useful in procedures requiring the drainage of
This must be retracted to visualize the distal end
sepsis.
of the ligament to ensure complete decom-
pression. The proximal end of the wound should
also be retracted to ensure complete release under Closure
direct vision with either tenotomy scissors or a
Skin closure is performed with 4-0 interrupted
blade.
nylon sutures. An occlusive dressing is applied,
The deep motor branch of the median nerve
followed by a compressive hand dressing. The
can have a variable course. Usually, it arises on the
compression dressing should allow immediate
radial side of the median nerve as the nerve exits
mobilization of the fingers and wrist and should
the carpal tunnel. The nerve continues radially,
not be excessively bulky.
entering the thenar muscles between abductor
pollicis brevis and FPB. However, variations may ENDOSCOPIC DECOMPRESSION
include a motor branch arising from the median
nerve within the carpal tunnel, running distally to Endoscopic decompression may be performed
pierce the retinaculum supplying the thenar through the Brown two-portal or the Agee single
muscles. Bearing this in mind during the portal technique. The main proven benefits of the
48 Surgery of the peripheral nerve
Deep dissection
Once the nerve and artery are identified
proximally, they are traced distally where they
enter Guyon’s canal. The volar carpal ligament is
Ulnar proper incised taking care not to damage the nerve or
digital artery (Fig. 5.6). The hook of hamate is then
nerve to the
4th common identified. Incising the edge of the hypothenar
small finger
digital nerve muscles reveals the deep motor branch as it
Hypothenar Thenar muscle continues around the hook of hamate.
muscle
Incising the volar carpal ligament, the palmaris
Deep motor brevis muscle and the hypothenar fibrous tissue
branch
will decompress the ulnar nerve within Guyon’s
of the ulnar
nerve canal. The nerve need not be completely
Pisohamate circumferentially dissected out as this may
ligamnet devascularize it. Distally, the interval between the
pisohamate and pisometacarpal ligaments is
explored for any masses, fibrous bands or fracture
Pisifrom
fragments. The superficial branch passes
Palmar carpal
Ulnar Ulnar superficial to the fibrous arch of the hypothenar
ligament
nerve artery muscles. The ulnar artery must be examined at
this point to ensure that it is free of aneurysm or
Figure 5.4 The relations of Guyon’s canal thrombus – it should be smooth and not tortuous.
50 Surgery of the peripheral nerve
Ulnar nerve
Ulnar artery
Flexor carpi ulnaris
Figure 5.5 The incision for ulnar nerve decompression at the wrist
RECOMMENDED REFERENCES
Green DP. Green’s Operative Hand Surgery, 5th
edn. Philadelphia: Elsevier, 2005.
Volar carpal Ulnar nerve
ligament and artery Polatsch DB, Melone CP, Beldner S, et al. Ulnar
nerve anatomy. Hand Clin 2007;23:283–9.
Waugh RP, Pellegrini DV. Ulnar tunnel syndrome.
Figure 5.6 Incision of the volar carpal ligament Hand Clin 2007;23:301–10.
Ulnar nerve decompression at the elbow 51
essential that the longitudinal vascular supply of Waugh RP, Zlotolow DA. In situ decompression of
the nerve is left intact and that the motor the ulnar nerve at the cubital tunnel. Hand Clin
branches are protected and allowed to move with 2007;23:319–27.
the main body of the nerve.
Once the nerve is decompressed and easily
transposable anterior to the medial epicondyle, a PRINCIPLES OF SURGERY ON
subcutaneous fascial flap is elevated with a scalpel. PERIPHERAL NERVES
The nerve is placed anterior to the deep surface of
the flap and the distal flap edges are sutured to PREOPERATIVE PLANNING
deep dermal tissue with an absorbable 3-0 Vicryl
suture. The wound is then closed as normal. The aims of surgery are:
• To confirm a diagnosis and establish prognosis
Closure • To restore function
• To relieve pain.
The wound is closed with interrupted 2-0 Vicryl
sutures for the subcutaneous layer and a running Indications
subcuticular monofilament suture for skin. If a
tourniquet has been used it should be released and • Closed traction injury of the brachial plexus
followed by meticulous haemostasis. A sterile leading to severe paralysis
dressing should be applied and then a compressive • Associated nerve and vascular injury
dressing over it. • Nerve injury with an associated fracture
requiring early internal fixation
POSTOPERATIVE CARE AND • Increasing progression of a neurological injury
INSTRUCTIONS or an entrapment neuropathy
• Failure of recovery of a lesion within an
Dressings are removed at 3–4 days. Range of expected timeframe
motion exercises within the limits of comfort • Failure of recovery in conduction block within
should be started at the same stage. Active hand 6 weeks of injury
and wrist motion is encouraged at all times. • Persistent pain following injury
The wound should be checked at 2 weeks and • Severe paralysis of a nerve following blunt
the patient advised on appropriate care of the scar. trauma.
Heavy lifting should be avoided for 1 month. It is
important to counsel the patient that not all
Contraindications
symptoms may be relieved by the surgery and that
recovery may take up to 6 months. • Active infection
• Function unaffected by nerve injury.
RECOMMENDED REFERENCES
Catalano LW, Barron OA. Anterior subcutaneous Consent and risks
transposition of the ulnar nerve. Hand Clin
2007;23:339–44. • Infection
Mowlavi A, Andrews K, Lille S, et al. The • Nerve damage/failure of repair
management of cubital tunnel syndrome: a meta- • Vascular injury
analysis of clinical studies. Plast Reconstr Surg • Specific to the site of operation, e.g. local
2000;106:327–34. structures at risk
O’Driscoll SW, Jaloszynski R, Morrey BF, et al.
Origin of the medial ulnar collateral ligament. J Operative planning
Hand Surg Am 1992;17:164–8.
Osterman AL, Spiess AM. Medial epicon- Earlier surgery following nerve injury permits
dylectomy. Hand Clin 2007;23:329–37. easier identification of tissues (due to less scar
54 Surgery of the peripheral nerve
tissue) and therefore any repair is easier as it is absence of recording distally is a relative
possible to visualize and match the arrangement indication to resect and repair the nerve,
of the cut ends of the nerve fascicles. The results depending on the macroscopic fascicular structure
of prompt repair are also markedly better due the seen. Care should be taken not to undertake
favourable biological environment for nerve excessive mobilization, as this may lead to
healing. A nerve stimulator should be available. devascularization of a nerve.
Magnification of at least three times with loupes is Bipolar diathermy should be used at all times
helpful. If nerve grafting is likely to be performed, when coagulating blood vessels around nerves.
a suitable donor graft should be identified
preoperatively and the patient made aware of the METHODS OF REPAIR
need.
Primary repair
Anaesthesia and positioning
The ends of an injured nerve are cut back
Surgical procedures involving the exploration/ progressively until the cut surfaces show bulging
repair of peripheral nerves should be performed healthy nerve bundles. An end-to-end anastomosis
under general anaesthesia, with antibiotic cover to is performed, which is possible if the resection gap
minimize the chance of any postoperative has been small, little mobilization of the nerve has
infection. Where possible, a tourniquet is used to been necessary, and the nerve is not under tension.
achieve a completely bloodless field, facilitating Flexing a nearby joint reduces tension on a nerve,
ease of identification of structures. Remember and extra length can be gained by transposition
that after approximately 15 minutes of ischaemia, (e.g. anterior transposition of the ulnar nerve) of a
nerve conduction becomes abnormal so any nerve. The two principal types of primary repair
tourniquet should be released when stimulating a are epineural repair and fascicular repair.
nerve. Epineural repair is technically less demanding and
faster to complete. Fascicular repair (Fig. 5.8) is
SURGICAL TECHNIQUE performed if there has been a clean transection of
a nerve trunk (e.g. in the brachial plexus). In each
Incision method of repair the true epineurium is exposed.
In a fascicular repair the matched bundles are
The course of cutaneous nerves should always be opposed and sutured with perineurial 11-0 nylon
remembered when planning a skin incision. A sutures and then 10-0 nylon sutures are passed
painful neuroma may result from a transected through the perineurium and epineurium. This is
cutaneous nerve and lead to considerable done circumferentially to complete the repair. In
morbidity to the patient. an epineurial repair (Fig. 5.9), the fascicular
groups in the nerve ends are matched as closely as
Nerve assessment possible and the ends are then sutured with 10-0
nylon sutures through the epineurium. An initial
When nerves have been damaged and surgery has suture is placed at each of the lateral ends of the
been delayed, a neuroma will have formed. The nerve, with interrupted sutures subsequently
consistency of a neuroma is important when placed on the anterior and posterior aspect of the
assessing nerve injury, as a hard neuroma may nerve to complete the repair.
represent an abundance of connective tissue and
little in the way of nerve tissue. Making an incision Nerve grafting
through the damaged epineurium permits
visualization of any nerve bundles present, and Cable grafts (Fig. 5.10) are the gold standard for
stimulation of the nerve proximally. This may give bridging gaps between two cut ends of a nerve
some indication as to likely recovery. Stimulating where primary repair is not possible. Nerve
the nerve proximally and recording from the bundles are matched to bundles; this is achieved
nerve distally gives the best guide for recovery. An by viewing and matching the nerve ends either
Principles of surgery on peripheral nerves 55
After nerve repair and grafting, the limb is • Spinal accessory nerve surgery
generally protected in a plaster with a sling (or • Suprascapular nerve surgery
crutches in the lower limb) for a period of • Sympathetic chain surgery.
between 3 and 6 weeks. Either outpatient or
inpatient therapy (as in the case of a brachial
plexus repair) is required to overcome any Landmarks
residual stiffness and deformity. This may include
appropriate splintage and is often multi- The landmarks for the supraclavicular approach
disciplinary, with occupational therapy, are those of the posterior triangle of the neck. The
physiotherapy and pain team input. base is formed by the clavicle, the medial border is
formed by the medial border of the
sternocleidomastoid muscle, and the lateral border
PRINCIPLES OF BRACHIAL PLEXUS by the edge of the trapezius muscle.
SURGERY
Indications
• Complete exposure of brachial plexus (when
combined with supraclavicular approach)
• Infraclavicular brachial plexus repair.
Dissection
Essentially this is analogous to the deltopectoral
approach to the upper humerus. The difference
lies in mobilizing the cephalic vein medially and
detaching and reflecting the pectoralis minor
muscle from the coracoid process. In a full
exposure, the pectoralis major insertion on the
humerus may also be detached.
Figure 5.11 Incision for the Fiolle Delmas approach to
FIOLLE DELMAS APPROACH the brachial plexus
Indications
facilitate access, especially if there is a vascular
The Fiolle Delmas approach combines the
injury. In this case a plate should be precontoured
supraclavicular and infraclavicular approaches and
and holes predrilled for easy fixation at the end of
is useful in an extensive injury to the plexus.
the procedure, remembering that the bone will be
shortened by the thickness of the saw blade.
Incision Distally the pectoralis major muscle is detached
from the humerus in its upper portion or, if
The platysma, with skin flaps is elevated and the
required, its entirety. The muscle is then reflected
mid-portion of the clavicle is exposed superiorly
medially exposing the clavicle, pectoralis minor
and inferiorly. An extension is made of the collar
muscle and the clavipectoral fascia (Fig. 5.12).
incision to expose the supraclavicular portion (Fig.
The pectoralis minor muscle is divided at its
5.11). This extension starts at around the mid-
tendon taking care not to damage the
portion of the supraclavicular incision and extends
musculocutaneous nerve. The subclavius muscle is
distally over the mid-portion of the clavicle
divided with the suprascapular vessels (once
running over the delto-pectoral groove to the
ligated). This exposes the entire plexus and
axilla. It is a true extensile approach and can be
vasculature from the first rib to the axilla.
continued distally, if necessary, as the anterior
approach to the humerus. When the infraclavi- POSTOPERATIVE CARE AND
cular is combined with the supraclavicular INSTRUCTIONS
approach, full exposure is given from the second
part of the subclavian artery to the terminal Following nerve repair/transfer, the limb may
portion of the axillary artery, with exposure of the require immobilization in a cast for 3 weeks after
brachial plexus from the spinal nerves to terminal which the patient can start motion progressively.
branches of the plexus. In the case of brachial plexus surgery, a sling is
applied with a body strapping for 3 weeks,
Dissection followed by readmission for a week at 6 weeks
post index operation to start the rehabilitation
A clavicular osteotomy may be required to process.
58 Surgery of the peripheral nerve
Subclavian vein
Deltoid
Subclavius
divided
Pectoralis major
divided
Figure 5.12 Dissection in the Fiolle Delmas
Pectoralis minor
approach to the brachial plexus
Viva questions
1. Describe the landmarks and incision for a 6. Describe the techniques used in primary nerve
carpal tunnel decompression. repair.
2. Describe the main structures at risk in a carpal 7. What options are available if primary repair is
tunnel decompression. not possible?
3. What are the sites of compression of the ulnar 8. What are the principal considerations for
nerve at the elbow? successful nerve transfer surgery?
4. What are the surface landmarks for Guyon’s 9. What are the priorities in gaining function
canal? after brachial plexus injury?
5. Which structures commonly cause ulnar tunnel
compression neuropathy at the elbow?
6
Surgery of the shoulder
Omar Haddo and Mark Falworth
Portals
The accurate placement of arthroscopic portals is
essential in shoulder arthroscopy. A variety of
portals can be used. The commonest viewing
portal is the posterior portal. A stab incision to the
skin is placed 2 cm medial and 2 cm inferior to the
posterolateral corner of the acromion. This
correlates to a palpable soft spot which denotes
the plane between the infraspinatus and teres
minor.
To access the glenohumeral joint, the scope is
Figure 6.1 aimed inferomedially towards the tip of the
Positioning and coracoid. The glenoid rim and the humeral head
traction for shoulder can be palpated and the scope can be pushed
arthroscopy between them. A popping sensation is usually felt
Diagnostic shoulder arthroscopy 61
as the joint is entered. Once the posterior portal is must enter the bursa and show the acromion and
established all other portals are made using an the bursal aspect of the cuff clearly. If cobweb-like
outside-in technique in which a spinal needle is tissue is seen, then the scope is outside the bursa
used to determine the exact location and angle of and should be repositioned. This is important as
entry into the joint. the bursa helps to contain the irrigation fluid, thus
A standard low anterior portal can also be used limiting soft tissue swelling around the shoulder.
for passing instruments into the joint. It is placed The lateral portal is 5 cm (three fingers breadth)
above the lateral half of the subscapularis but distal to the acromion and 1 cm anterior to the
medial to the medial biceps pulley. Once the mid-lateral line (in line with the posterior line of
needle has been placed in the appropriate position the ACJ). This portal is used for instrumentation
the portal is made using a size 11 scalpel, which is of the subacromial space (Fig. 6.2).
inserted in the same direction as the needle taking Other portals can be made on demand. These
care to avoid the long head of the biceps (LHB). include the anterosuperolateral, accessory
To enter the subacromial space, the same anterior, accessory lateral, accessory posterior and
posterior portal skin incision is used; however, the Neviaser (superior) portals. A cannula may be
scope is aimed superolaterally towards the used if proceeding to a therapeutic procedure.
anterolateral corner of the acromion. The scope Clear cannulas are recommended as they allow
visualization and aid in suture management.
Procedure
tendon insertion can be best visualized with the POSTOPERATIVE CARE AND
arm in internal rotation. INSTRUCTIONS
• By gently withdrawing the scope and looking
laterally, the posterior pulley of the LHB can be If the procedure is purely diagnostic no sling is
viewed and then the supraspinatus and necessary. The patient is encouraged to mobilize
infraspinatus tendons can be examined. The as soon as possible.
bare area and any Hill–Sachs lesions can now be
identified. RECOMMENDED REFERENCE
• As the arthroscope is taken further inferiorly it
Levy O, Sforza G, Dodenhoff R, et al. Evaluation
enters the inferior recess. The reflection of the
of the impingement lesion: pathoanatomy and
inferior capsule and the posterior band of the
classification. Arthroscopic evaluation of the
inferior glenohumeral ligament (hammock
impingement lesion: pathoanatomy and classifica-
effect) can be seen. By then rotating the scope,
tion. J Bone Joint Surg Br 2000;82B(Suppl 3):233.
the posterior inferior labrum can be visualized
and then the entire posterior and superior
labrum examined before assessing the chondral
surfaces of both the humeral head and ANTERIOR ACROMIOPLASTY – OPEN
glenoid.
• The anterior stabilizing structures can now be PREOPERATIVE PLANNING
examined. Superiorly the sublabral foramen,
labrum and the middle glenohumeral and Common indications
anterior band of the inferior glenohumeral
ligaments can all be visualized. • Impingement with failure of conservative
• An anterior portal can be made through the management
rotator interval for the introduction of a probe • In association with: rotator cuff repair, shoulder
for further assessment of any soft tissue arthroplasty, malunion of greater tuberosity
pathology or if any glenoid bone loss needs to fracture.
be further assessed.
• The subacromial space should then be Contraindications
examined. Superiorly the acromion is seen,
anteriorly the coracoacromial ligament and Relative: Irreparable cuff tear to avoid superior
inferiorly the bursal side of the rotator cuff. The escape of the humeral head. (A limited
presence of bursal side rotator cuff tears, decompression can be undertaken).
impingement lesions and acromial and ACJ
pathology can all be assessed.
Consent and risks
This is just one example of a systematic assess-
ment of arthroscopic shoulder anatomy. Each • Infection
surgeon can develop their own system, however, it • Neurovascular injury
is essential that all surgeons are familiar with • Stiffness
arthroscopic anatomy and normal variations. • Fracture of the acromion: can occur if the
osteotomy is performed in the wrong plane or if
excess bone is resected
Closure • Detachment of the deltoid
• Failure of procedure: wrong indications,
Portals can be left unsutured or closed with incomplete decompression, missed cuff tear
subcuticular 3/0 Monocryl sutures.
Anterior acromioplasty 63
SURGICAL TECHNIQUE
Landmarks
• Acromioclavicular joint
Figure 6.3 The
• Anterolateral corner of acromion correct orientation
• Tip of the coracoid. for the acromion
osteotomy
Incision
This procedure is rarely performed as an isolated
open procedure as it is most commonly per-
formed arthroscopically or in association with a Closure
larger open procedure. As such, the skin incision
A good deltoid reconstruction is essential. If the
will be dictated by the other procedure, however,
quality of the osteoperiosteal flaps is poor, a
if it is to be performed as an isolated open
transosseous repair using no. 2 Ethibond is
procedure, a 2–3 cm anterosuperior incision is
performed followed by subcutaneous 2/0 Vicryl
made over the anterior acromion.
and 3/0 Monocryl to skin.
Neer CS. Anterior acromioplasty for chronic coracoacromial ligament detached. The lateral
impingement syndrome in the shoulder – a edge of acromion must be exposed to ensure
preliminary report. J Bone Joint Surg Am adequate lateral decompression.
1972;54:41–50. A barrel burr/shaver is used for bone resection.
If the acromion has a lateral down-slope then a
lateral bevel is performed. The decompression is
ARTHROSCOPIC SUBACROMIAL then performed by excising the anterior
acromion, from lateral to medial. The acromial
DECOMPRESSION branch of the coracoacromial vessel is at risk at
this stage. Anterior resection is usually
PREOPERATIVE PLANNING approximately 4 mm (the width of the burr) or
until the anterior deltoid attachment is reached.
See ‘Anterior acromioplasty – open’ (p. 62). Medially, the resection is limited by the ACJ. The
undersurface of the acromion is then chamfered,
SURGICAL TECHNIQUE to smooth out any ridges (Fig. 6.4).
Further refinement of the acromioplasty can be
See ‘Diagnostic shoulder arthroscopy’ (p. 60) for
performed by placing the arthroscope in the
positioning and portals.
lateral portal and the shaver posteriorly. Any
residual bone can be resected using the posterior
Procedure acromion as a ‘cutting-block’, thus creating a flat
undersurface to the acromion.
Structure at risk
Closure
• Acromial branch of the coracoacromial artery
See ‘Diagnostic shoulder arthroscopy’ (p. 60).
RECOMMENDED REFERENCES
Levy O, Sforza G, Dodenhoff R, et al. Evaluation
of the impingement lesion: pathoanatomy and
classification. Arthroscopic evaluation of the
impingement lesion: pathoanatomy and
classification. J Bone Joint Surg Br 2000;82B(Suppl
3):233.
Gartsman GM. Arthroscopic acromioplasty for 1cm
ACROMIOCLAVICULAR JOINT
resected distal clavicle (Fig. 6.5). Care must be
EXCISION taken not to resect too much distal clavicle
otherwise distal clavicular instability can occur.
PREOPERATIVE PLANNING Any osteophytes on the undersurface of the
acromion are trimmed with bone nibblers and any
Indications residual meniscus removed.
Closure
Anaesthesia
See ‘Arthroscopic subacromial decompression’ Anaesthesia is usually combined general and
(p. 64). regional.
aspect of the ACJ and is directed towards the mini-open approach need be adopted. The con-
anterolateral corner of the acromion and down figuration and tension of the mobilized cuff tear is
the anterior deltoid raphe. A smaller incision can then assessed in order to plan the repair.
be performed if an arthroscopic decompression A shallow bony trough/footprint is prepared
has already been performed such that a mini-open using an osteotome (or burr in a mini open) at the
procedure can be undertaken. level of tendon insertion. This should be made just
lateral to the articular surface. The method of the
Dissection tendon repair is determined by the operating
surgeon.
The deltoid is bluntly split at the anterior raphe Single and double row anchor repairs can be
(junction of the anterior and middle thirds). The undertaken depending on the size of the tear or
deltoid is detached off the anterior acromion with alternatively a transosseous suture repair can be
an osteoperiosteal sleeve. The bursa is split performed. In the latter method the tendon is
longitudinally. The inferior reflection of the bursa repaired with a no. 2 Ethibond Mason Allen
denotes the position of the axillary nerve which suture. In each method the aim is to achieve
can be palpated and avoided thereafter (Fig. 6.6). healing of the tendon to the footprint.
The coracoacromial ligament is detached from the
undersurface of the acromion. Closure
Portals
Posterior, anterior, lateral and accessory lateral
portals are often required. The superior Neviaser
portal can be useful for passing sutures through
the cuff, particularly in massive tears.
Procedure
Glenohumeral arthroscopy is performed and any
concurrent pathology assessed and treated as
Axillary
nerve
necessary. The cuff is then assessed with respect to
Figure 6.6 The its size, shape and mobility. The arthroscope is
relationship of the then inserted into the subacromial space and a
Inferior reflection subdeltoid bursa to subacromial decompression (± ACJ excision) is
of subdeltoid bursa the axillary nerve performed as necessary. Any releases are then
68 Surgery of the shoulder
Landmarks
ACROMIOCLAVICULAR JOINT
RECONSTRUCTION – MODIFIED • ACJ
WEAVER–DUNN • Anterolateral corner of the acromion
• Tip of coracoid
PREOPERATIVE PLANNING
SURGICAL TECHNIQUE
Indications The technique will vary depending on whether an
acute or chronic injury is being addressed. Acute
• Chronic type IV–VI ACJ dislocation
injuries do not require a ligament transfer
• Chronic type III in the young, athletic, manual
procedure as part of the reconstruction. Chronic
worker, dominant side (surgery on Grade III AC
injuries are best managed with a biological
joint dislocation is more controversial than
reconstruction which is supplemented by another
conservative treatment and is very much
fixation device until healing has occurred
surgeon dependent).
approximately 3 months post repair.
Contraindications Approach
Unreliable patient (important due to post- A strap incision, 1 cm medial to the ACJ, and
operative restrictions). extending down to the coracoid.
Procedure
Consent and risks The delto-trapezoidal fascia is incised
• Infection longitudinally along the distal clavicle with an
• Neurovascular injury extension across the superior acromioclavicular
• Stiffness capsule/ligament and further laterally over the
• Failure of the procedure or recurrence anterior acromion. The deltoid fibres are elevated
off the clavicle and, at the acromion, an
osteoperiosteal flap is raised to aid later repair. The
coracoacromial ligament is defined by sweeping
Operative planning bluntly laterally with a swab. It is then detached
from the acromion with a sliver of bone. It is then
Radiographs – anteroposterior, 30° cephalic, mobilized down to the coracoid and a whipstitch
axillary ± stress views – are required. applied to the ligament with no. 2 Ethibond. The
distal 1 cm of the clavicle is excised obliquely with
an oscillating saw. The bone fragment is retained
Anaesthesia and positioning for later autologous bone graft.
The clavicle is reduced to its anatomical position
Anaesthesia is usually general, regional or by reducing the arm back up to the clavicle and by
combined. Where general anaesthesia is used further reducing the clavicle downwards and
alone, local anaesthetic is recommended for forwards. This position must be maintained prior
postoperative pain relief. to the ligament transfer. This can be achieved by a
The patient is placed in the beach chair number of techniques, including a Bosworth
position. A small sandbag is put under the screw, three strands of PDS cord (Johnson and
shoulder. An arm board can be attached to the Johnson) looped around the coracoid and clavicle
side of the table to rest the arm on. The surgical or, with a TightRope reconstruction device
field is prepared and adequately draped. (Arthrex Inc; Naples, FL, USA).
70 Surgery of the shoulder
Once held in the reduced position two 2 mm reconstruction; 2/0 Vicryl is used for closure of
drill holes are then made in the superior cortex of the subcutaneous tissues and 3/0 Monocryl is used
clavicle. The bony fragment of the for skin.
acromioclavicular ligament is passed into the
intramedullary canal and the two sutures are POSTOPERATIVE CARE AND
passed through the holes, tensioned and tied (Fig. INSTRUCTIONS
6.8). An autograft from the resected distal clavicle
is then used to graft any redundant space around • Six weeks in a sling with passive, and active
the transferred ligament. assisted, forward elevation to 90° and external
In acute cases (<3–4 weeks post injury) the rotation to 30°
coracoclavicular ligaments and superior • Progress to active shoulder movement, below
acromioclavicular capsule/ligament can be shoulder height, from 6 weeks with passive
repaired and then supplemented with one of the stretching above shoulder height at 10 weeks
stabilizing techniques described above. A • Strengthening at 12 weeks (if a Bosworth screw
Weaver–Dunn ligament transfer is not required. is used shoulder movement must be restricted
to below shoulder height until the screw is
Closure removed at 3 months).
Incision
Consent and risks
The skin incision runs in the deltopectoral groove,
• Infection from the coracoid to the axillary fold (with the
• Stiffness, particularly loss of external rotation arm adducted and internally rotated).
• Recurrence
• Subscapularis detachment.
Superficial dissection
• Neurovascular injury
Structure at risk
Operative planning
• Cephalic vein
Recent radiographs and CT/MRI arthrogram
should be available to the surgeon. Examination
under anaesthetic ± diagnostic arthroscopy should The subcutaneous tissue is reflected with sharp
be performed prior to the procedure. and electrocautery dissection, exposing the
deltopectoral interval which is marked by a fatty
streak and the cephalic vein. The fascia overlying
SURGICAL TECHNIQUE – the interval is divided and the cephalic vein
ANTEROINFERIOR STABILIZATION lateralized with the deltoid muscle. The deltoid
and pectoralis major are then defined with sharp
Anaesthesia and positioning and electrocautery dissection.
clavipectoral fascia is then split vertically starting to reattach the anterior labrum to the
just lateral to the coracoid. This exposes the decorticated area of the glenoid neck. The
conjoint tendon. If required, the lateral third of capsular flaps are overlapped so that the inferior
the conjoint tendon can be divided to allow better flap is taken superiorly and medially such that it is
exposure (by not detaching the coracoid or the sutured to the medial capsule. A double-breasted
tendon fully, the musculocutaneous nerve is suture technique using 1 Vicryl should be used.
protected from excessive traction). A self-retainer The superior flap is then sutured inferiorly taking
is placed between the coracoid/conjoint tendon care not to medialize the flap otherwise external
medially and the deltoid muscle laterally. rotation will be restricted. The rotator interval is
The arm is externally rotated to expose the then closed (Fig. 6.10).
subscapularis muscle. The upper two-thirds of the During the repair, the arm should be held in
subscapularis can then be tenotomized 30° of external rotation and abduction so that the
approximately 1 cm from its insertion in the lesser repair is not over tightened thus causing
tuberosity and dissected free of the underlying
capsule. This plane is more easily found inferiorly
and becomes easier as the dissection progresses
medially. Alternatively, the subscapularis can be
split horizontally and retracted, exposing the
underlying capsule.
Procedure
The capsulorrhaphy must now be undertaken.
This can be performed either laterally or medially.
It is the authors’ preference to perform this
medially as we feel it gives a more accurate
anatomical reconstruction and a more
Subscapularis
reproducible elimination of the axillary pouch. split
To achieve a large inferior capsular shift the
capsule must be dissected off all of its muscular
attachments inferiorly and, indeed, postero- Figure 6.9 The medial ‘T’-shaped capsular incision
inferiorly in cases of marked laxity. This is best
achieved with McIndoe scissors. A bone lever can
then be placed inferior to the humeral neck thus
protecting the axillary nerve. Depending on the
degree of laxity the capsulorrhaphy can involve
either a vertical capsular incision or, in cases of
greater laxity, a medially based ‘T’.
The capsule is split vertically 7–10 mm from
the glenoid rim, with a further horizontal incision
made midway along the capsule as necessary (Fig.
6.9). Two stay sutures are placed to mark the
superior and inferior apices of the flaps. A Fakuda
retractor is used to displace the humeral head
posteriorly such that the anterior labrum is
exposed. The presence of a Bankart lesion, and the
degree of capsule–labral disruption, can now be Inferior
visualized. capsular shift
The anterior glenoid neck is decorticated using
a narrow osteotome or burr and anchors are used Figure 6.10 Medially based inferior capsular shift
Shoulder stabilization 73
postoperative stiffness. Adequate stability and a access to the underlying infraspinatus and teres
good passive range of motion should be confirmed minor tendons. More laterally an osteoperiosteal
before the wounds are closed. flap should be raised off the posterior lateral
If a large, engaging Hill–Sachs lesion is present corner of the acromion with, if necessary, a further
a bone block procedure (Bristow–Latarjet or iliac extension down the posterior deltoid raphe.
crest bone graft) will be required to increase the The interval between the infraspinatus and
depth of the glenoid to prevent recurrent teres minor can be developed by blunt dissection
dislocation. A soft tissue procedure alone will not exposing the posterior capsule.
be adequate to restore stability.
Procedure
Closure
The procedure for the repair of a posterior labral
If previously tenotomized, the subscapularis injury and /or capsular laxity is similar to that
should be repaired with no. 2 Ethibond. described for an anteriorly based injury. A medial
Thereafter, a layered closure using 2/0 Vicryl for or laterally based capsulorrhaphy can be
the subcutaneous tissues and 3/0 Monocryl to skin performed although we favour the former for the
is used. reasons described earlier.
Rowe CR, Zarins B, Ciullo JV. Recurrent anterior such that angle of approach allows accurate suture
dislocation of the shoulder after surgical repair. anchor placement. This can be best assessed using
Apparent causes of failure and treatment. J Bone the anterosuperior viewing portal. A clear cannula
Joint Surg Am 1984;66:159–68. is recommended for better visualization.
te Slaa RL, Wijffels MP, Brand R, et al. The
prognosis following acute primary glenohumeral Procedure
dislocation. J Bone Joint Surg Br 2004;86:58–64.
Glenohumeral arthroscopy is carried out. The
degree of tissue separation and amount of anterior
ANTERIOR REPAIR OF INSTABILITY – or inferior capsular laxity are assessed. The drive-
ARTHROSCOPIC through sign is noted. This reflects the ease
with which the scope is passed between the
PREOPERATIVE PLANNING humeral head and the glenoid and is a sign of
significant laxity. The Bankart lesion is released
For primary indication/contraindications/consent around to the 6 o’clock position on the glenoid,
and risks/operative planning, see ‘Shoulder with sharp elevators. A sufficient release is
stabilization – open’ (p. 73). confirmed by grabbing the inferior tissue with a
manipulator and elevating it superiorly against the
Anaesthesia and positioning glenoid rim.
The anterior glenoid (2–6 o’clock) is
Anaesthesia is usually general, regional or decorticated with a rasp and shaver (ensure that
combined. Where general anaesthesia is used suction is clamped during this stage). An anchor is
alone, local anaesthetic is recommended post- placed at the 5 o’clock position on the glenoid
operatively for pain relief. The patient is in the rim. A suture is passed through the tissue
beach chair or lateral position (see ‘Diagnostic inferiorly using a penetrator or suture shuttle
shoulder arthroscopy’ (p. 60)). technique. The amount of tissue included in the
suture is critical as it will dictate the degree of
Landmarks stability following the repair. To help reduce the
labral tissue back to the glenoid rim the knot can
See ‘Diagnostic shoulder arthroscopy’ (p. 60). be tied with the arm in flexion and internal
rotation. Capsular plication (weaving of sutures
SURGICAL TECHNIQUE through the capsule) can also be performed in
cases of marked capsular laxity. Further anchors
Examination under anaesthesia are placed at 4 o’clock and 3 o’clock positions to
approximate the labrum and perform a distal to
As for open stabilization. proximal shift of the capsule (Fig. 6.11).
Portals Closure
A standard posterior viewing portal is used to 3/0 Monocryl to cannula portals.
assess the labral and capsular pathology.
Using an outside-in technique, an antero- POSTOPERATIVE CARE AND
superolateral portal is placed at the junction of the INSTRUCTIONS
anterior border of the supraspinatus tendon and
the upper rotator interval. It should allow a 45° See ‘Shoulder stabilization – open’ (p. 73).
angle of approach to the superior labrum. This
will provide both an anterior viewing portal and RECOMMENDED REFERENCE
an accessory portal for SLAP repairs or for suture
management. A further anterior portal is placed Hobby J, Griffin D, Dunbar M, et al. Is
just above the subscapularis tendon. This is placed arthroscopic surgery for stabilisation for chronic
Total shoulder replacement 75
Structure at risk
Contraindications
• Cephalic vein
Active infection.
76 Surgery of the shoulder
The subcutaneous tissue is reflected with sharp planned at this stage. If external rotation is
and electrocautery dissection exposing the adequate the subscapularis tendon is then
deltopectoral interval, which is marked by a fatty tenotomized 1 cm medial to its humeral insertion
streak and the cephalic vein. The fascia overlying and raised on stay sutures. This can be taken as one
the interval is divided and the cephalic vein layer with the underlying capsule. In order to
lateralized with the deltoid muscle. In a tight lengthen the subscapularis the rotator interval will
shoulder the pectoralis major tendon can be need to be incised and then the capsule will need
released at its superior border taking care not to to be released from the glenoid neck.
injure the underlying biceps tendon. As the capsule is incised an inferior capsular
release can be performed, and provided that the
Deep dissection axillary nerve has already been identified the nerve
should not be at risk. A blunt retractor can be
Structures at risk placed inferiorly to protect the nerve and then the
humeral head is dislocated anteriorly by applying
The axillary and musculocutaneous nerves are in gentle external rotation to the arm. The LHB
danger from excessive traction. tendon should be inspected and tenotomized or
tenodesed as necessary.
To enhance the exposure a retractor can be placed The head is then prepared by removing any
over the coracoid process and then the clavi- osteophytes so that the true anatomical neck of the
pectoral fascia is split vertically starting just lateral humerus is identified. The head can now be
to the coracoid, extending the incision just lateral prepared for the shoulder replacement; the
to the conjoint tendon and its muscle belly. preparation will vary depending on the implant and
To improve external rotation the coraco- whether a resurfacing type prosthesis is to be used.
humeral ligament should also be released at its For the purpose of this description, a standard
coracoid origin. The deltoid is then mobilized stemmed implant will be used. An oscillating saw is
from the tissues of the subacromial space and used to resect the humeral head at its anatomical
retracted posterolaterally. Provided that the neck. If this has been adequately demarcated
retractors are placed above the inferior subdeltoid during your preparation it can be done freehand
bursal reflection the axillary nerve should be safe. otherwise jigs should be used such that the height
If better access is required, as may be the case and version of the resection is appropriate. The
with a medialized glenoid, the lateral third of the resected humeral head is then used as a guide for
conjoint tendon can be divided to allow better the size of the subsequent humeral head
exposure or alternatively a coracoid tip osteotomy replacement. With the head resected the remainder
can be performed. However, care should be taken of the circumferential glenoid release can be
not to retract the conjoint tendon excessively as performed and the glenoid inspected.
this could put the musculocutaneous nerve at risk. Once the capsule is released there should be
The arm is externally rotated to expose the adequate space to approach the glenoid
subscapularis muscle. perpendicular to its face such that glenoid
The anterior circumflex humeral vessels, which preparation can be achieved with the appropriate
are found at the inferior border of the implant jigs. The process of this preparation will
subscapularis tendon, are then ligated. The vary according to the implant, however, to assess
axillary nerve can then be exposed so that its the true version of the glenoid it is useful to place
position is known and avoided during the a narrow retractor down the anterior glenoid neck
remainder of the procedure. so that the axis of the glenoid is known prior to
The degree of external rotation that can be definitive glenoid preparation.
achieved should now be assessed. If this is deficient The humerus is now prepared using
then a subscapularis lengthening procedure may be sequentially sized rasps and when the appropriate
required. This may involve a layered subscapularis size is established a trial prosthesis can be
tenotomy or ‘Z plasty’ and this will need to be constructed and inserted into the humerus. After
Total shoulder replacement 77
reducing the implant the surgeon should check from its insertion to the lesser tuberosity together
the offset, version and soft tissue tension of the with the capsule. Stay sutures are inserted.
trial prosthesis and if satisfactory the definitive If biceps tenodesis is required, a stay suture is
prosthesis can be implanted. placed and the tendon cut. The humeral head is
dislocated anteriorly with external rotation and
Anterosuperior extension. A Bankart skid is placed between the
glenoid and the head. Osteophytes are excised. A
Incision bone spike is inserted on the medial side of the
An 8 cm incision is started just posterior to the humeral neck, under the subscapularis to protect
front of the ACJ, directed towards the the axillary nerve. Humeral and glenoid
anterolateral corner of the acromion and down preparation is then performed as previously
the anterolateral deltoid. described.
Viva questions
1. Describe the deltopectoral approach. What 12. Describe your management of ACJ dislocation,
structures are at risk? including classification.
2. Describe the posterior approach to the 13. What are the indications for operative
shoulder. stabilization of the shoulder?
3. What are the advantages and disadvantages of 14. How would you classify shoulder instability?
the anterosuperior approach?
15. Would you do open or arthroscopic
4. Describe the anatomy of the axillary nerve. stabilization?
5. Describe the portals in shoulder arthroscopy. 16. What approach would you use for total
shoulder replacement?
6. What is the pathophysiology of impingement?
17. What are the indications for shoulder
7. Describe how you would do an arthroscopic
replacement?
subacromial decompression.
18. Would you replace the glenoid and why?
8. What are the indications for ACJ excision?
19. What are the complications of total shoulder
9. How do you classify cuff tears?
replacement?
10. What are the indications for rotator cuff
20. In what position would you arthrodese a
repair?
shoulder?
11. What are the complications from rotator cuff
repair?
7
Surgery of the elbow
Deborah Higgs and Simon Lambert
Operative planning
Figure 7.1 Patient position
Anteroposterior and lateral (in flexion and
extension) radiographs, less than 6 months old,
should be available.
For articular surface lesions a computed
tomography (CT) arthrogram is desirable. It access. The elbow should be sufficiently mobile
should be possible to readily convert from an for appropriate movement intraoperatively. The
arthroscopic procedure to an open procedure (see hand, forearm, and arm to the axilla are prepared
positioning and incision sections). with a germicidal solution. Waterproof drapes are
used with adhesive edges to provide a seal to the
skin. An antibacterial adhesive skin drape is
Anaesthesia and positioning applied.
Anaesthesia is usually general, augmented by
SURGICAL TECHNIQUE
infraclavicular regional nerve blockade if not
contraindicated (see above). An initial dose of Arthrolysis can be performed open or arthroscopically.
antibiotic is given intravenously. The antibiotic of
choice depends on local policy, but a common OPEN ARTHROLYSIS
choice is cefuroxime (1.5 g in the adult). Note: if
intraoperative biopsies are to be obtained to The choice of approach is governed by which
diagnose sepsis then the antibiotic is withheld compartment is to be accessed:
until the biopsy obtained. • For the lateral side of the anterior and posterior
The patient is placed in the lateral decubitus compartments: the lateral column (Morrey)
position with the operated arm uppermost. approach. This can be extended proximally into
Padded lumbar and pelvic supports are used. a lateral approach to the humerus, and distally
A Carter–Brain gutter or well-padded drape into a Kocher-type approach to the radial head
support is used to cradle the arm, allowing the and neck. The anterolateral compartment is
forearm to move freely in the vertical position, readily accessible (see ‘Radial head
permitting access to the dorsal aspect and both replacement’, p. 90)
sides of the elbow, and to the anterior • For the medial side of the anterior
compartment by external rotation of the shoulder compartment: the direct medial approach
(Fig. 7.1). Of note in this position: the ulnar nerve anterior to the ulnar nerve (see ‘Tennis/golfer’s
is always on the side of the elbow facing the feet elbow release’, p. 93)
of the patient (assuming there has been no • For the anterior compartment alone, e.g. for
previous operation on the ulnar nerve). lengthening of the biceps tendon: the anterior
A padded narrow tourniquet (inflation to 200 approach. This is a lazy-S incision respecting
mmHg is usually sufficient) or a S-MART the flexure crease of the elbow, passing from
bandage/tourniquet is used. At least 15 cm of the medial to the tendon of the biceps proximally
dorsal aspect of the arm is required for ease of over the brachial neurovascular bundle, to the
Elbow arthrolysis 81
Radial
nerve
Incision
7.5
7.5cm
cm
Ulnar
nerve
Incision
6 cm
medial side of the ‘mobile wad’ (Henry) distally continued distally parallel to the crest of the ulna
(Fig. 7.2) (not crossing it or on it) for approximately 6 cm
• For the dorsal (olecranon fossa) compartment (Fig. 7.3).
and ulnar nerve: the dorsal trans-tricipital
approach.
Superficial dissection
TRANS-TRICIPITAL APPROACH
Structure at risk
Landmarks
• Ulnar nerve
• Midline of the humerus
• Lateral epicondyle
• Radial head The triceps tendon is more correctly an
• Tip of the olecranon aponeurosis. There is a superficial sheet having a
• Crest of the proximal ulna. median vertical aponeurotic extension, between
the lateral and medial heads of the triceps, which
Incision leads to the deep head. This sheet is the guide to
the dissection of the triceps.
The incision is made in a curvilinear fashion The lateral and medial musculotendinous
towards the tip of the olecranon starting about 7.5 boundaries of the triceps are revealed by epifascial
cm proximal to the olecranon, skirting on its dissection in the proximal part of the wound.
lateral side, leaving between 0.5 cm and 1 cm Minimal epifascial dissection is used distal to the
between the incision and the lateral border of the olecranon over the subcutaneous border of the ulna,
olecranon (to avoid placing the incision on the sufficient only to see the deep antebrachial fascia
weightbearing skin of the elbow). The incision is over anconeus. Medial dissection is continued,
82 Surgery of the elbow
sufficient to reveal the ulnar nerve immediately border of the lateral head of triceps and the
subjacent to the medial border of the triceps proximal border of the anconeus. Dissection
about 6–7 cm proximal to the medial epicondyle. within the lateral head of triceps is to be avoided.
The triceps is split between the nerve and blood
Deep dissection supply to the medial head (a segmental branch
can occur very distally) and the nerve to the lateral
head, both derived from the radial nerve. The deep
Structures at risk head nerve supply is more proximal and is out of
the surgical field. The ulnar nerve is protected by
• Ulnar nerve keeping dissection lateral and then deep to the
medial head of the triceps, using the muscular
This approach respects the nerve supply to the bulk as a protection for the nerve (Fig. 7.4).
anconeus (an important contributor to elbow It is important to know where the ulnar nerve
stability): this is a distal branch of the radial nerve is if dissection of the medial capsule is likely, but
which crosses the interval between the distal the nerve does not need to be mobilized for
simple olecranon fossa debridement, or when the
radiocapitellar joint is the only compartment
entered.
The ulnar nerve is identified throughout its
course, behind the medial condyle, noting the
axial vessel and the vena comitans on the deep
Lateral head (articular) surface of the nerve in the cubital
Medial
head sulcus. The fibrous arch between the two bony
origins of the flexor carpi ulnaris (FCU) is incised,
the incision being carried into the muscle for
about 2 cm (Fig. 7.4), marking and protecting the
nerve branch to the FCU, which arises proximal to
the elbow, and allowing ready displacement of the
nerve from the cubital sulcus without tension.
Proximal dissection
Ulnar The triceps aponeurosis is incised in the midline
nerve and undermined to define the vertical sheet
Brachioradialis
between the two superficial heads of the triceps.
Incision
The dissection is then taken down the lateral
Anconeus side of this sheet, i.e. in the intervascular/
interneural plane to the deep head of the triceps.
Extensor The superficial heads are parted for about 6 cm,
carpi ulnaris uncovering the filmy layer between them and the
deep head. The deep head is then incised (the
Flexor
carpi ulnaris only muscular incision required in this technique)
noting the deep transverse epicondylar vessels
Ulna under the muscle at the proximal margin of the
fat pad in the olecranon fossa. The vessels are
cauterized. The fat pad is excised and the
olecranon fossa exposed. A posterior capsulec-
tomy is performed and any olecranon osteophytes
removed. An Outerbridge–Kashiwagi procedure
Figure 7.4 Trans-tricipital approach – deep dissection can now be planned (see below).
Elbow arthrolysis 83
Distal dissection
The antebrachial fascia is incised parallel to and
about 1 cm lateral to the crest of the ulna over the Lateral
anconeus. The dissection is taken under the fascia epicondyle
but outside the anconeus to the crest and then, on
bone, down to the supinator crest, the annular
ligament and capsule of the proximal radioulnar
joint, lifting the anconeus away from the capsule Triceps
and radial head, but preserving the posterior band
of the lateral collateral ligament (to maintain
stability in varus strain) (see Fig. 7.4).
This completes the exposure for the olecranon
fossa and the posterolateral (radiocapitellar)
compartment, permits excision of the radial head
if needed, and facilitates adhesiolysis of the
ulnohumeral surfaces.
Incision
Anconeus
Dissection for the lateral column and anterior
compartment: the lateral column and Extensor carpi
Kocher-type approaches ulnaris
(a) Brachioradialis
Triceps
Incision
Anconeus
Extensor
carpi ulnaris
Figure 7.6 Outerbridge–Kashiwagi procedure Figure 7.7a Incision maintaining lateral head of triceps
and anconeus in continuity.
(b) (c)
Capitellum
Olecranon
Incision over
lateral epicondylar
ridge
Radial
Supinator head
Elbow capsule,
opened
Figure 7.7b Deep disection showing incision over lateral Figure 7.7c Exposure of radial head.
epicondylar ridge.
Elbow arthrolysis 85
retained for about 8 weeks, before application of a full-radius resector and electrocautery. Any loose
removable hinged brace for a further 4 weeks. If bodies are removed. The coronoid fossa is re-
the ligaments can be restored to their optimal created, using the resector and a burr for any bony
tension an external hinged removable brace can be hypertrophy. The coronoid tip is removed if there
used. Re-fixation of the ligaments to their is evidence of coronoid impingement. The
footprint origins is facilitated by one of the several resector is used to strip the capsule proximally, off
varieties of anchors that are available. The elbow the distal humerus, for approximately 2.5 cm
must be stable enough to permit full-range proximal to the olecranon fossa until the fibres of
assisted sagittal motion with gravity eliminated brachialis come into view proximally. To complete
immediately after the operation. the release a 1 cm capsulotomy of the anterior
capsule medial to lateral is required.
Closure Using the direct posterior and posterolateral
portals the posterior compartment is debrided
The olecranon osteo-periosteo-fascial medallion is similarly. The scope enters through the
repaired by transosseous non-absorbable sutures posterolateral portal and the resector or burr
(no. 2 gauge) to the olecranon. A suction drain is through the direct posterior portal to complete
placed deep to triceps. The triceps aponeurosis the procedure. Careful release of the contracture,
and antebrachial fascia are closed with the elbow with a full-radius resector, releases the
flexed at 90° flexion using absorbable braided no.1 posteromedial and posterolateral gutters. Beware
interrupted sutures (continuous suturing reduces of the ulnar nerve in close proximity medially.
the ‘give’ of the tendon during assisted motion). Manipulation of the elbow is used to achieve
• The skin is closed with a dermal supporting maximum extension.
absorbable 3/0 suture and an absorbable 4/0
continuous subcuticular suture plus Steri- Closure
Strips.
• An occlusive dressing is applied with the elbow • A drain is placed in the direct posterior portal
in 90° of flexion. and the portals closed with absorbable sutures.
• A bulky wool and crepe bandage dressing is • Occlusive dressings are applied.
applied in two layers. • The elbow is splinted in maximum extension.
Operative planning
Recent radiographs must be available. Availability
of the implants must be checked by the surgeon. Figure 7.10 Radial head and tip olecranon excised
88 Surgery of the elbow
olecranon, along a line tangent to the posterior- aligned with the humeral canal. The medial
most portion of the olecranon articulation, are border should lie along the medial trochlea. The
excised with an oscillating saw (Fig. 7.10). guide should also align with the anatomic internal
To mark the humeral saw cuts, the olecranon rotation of the trochlea, which approximates the
fossa guide is available on the instrument set. To flat surface posterior and just proximal to the
orientate the guide, the shaft of the fossa guide is olecranon fossa. Using a fossa reamer, a hole is
created and an oscillating saw is used to remove
the remains of the trochlea, along the lines
previously marked, allowing access to the
medullary canal of the humerus (Fig. 7.11).
The canal is identified with a high-speed
rotating bur at the proximal aspect of the
resection of the olecranon fossa in a proximal
direction (Fig. 7.12). Open the medullary canal to
Figure 7.12 A high-speed a size sufficient to allow a humeral rasp (about
burr is used to identify 4 mm).
the humeral canal The humeral rasps are now used to prepare the
humeral canal (Fig. 7.13). Serial rasps increasing in
size are used until cortical resistance is met. If a
rasp is unable to be advanced fully, use an implant
corresponding to the largest size of rasp which
was fully introduced.
The medial and lateral portions of the
supracondylar columns must be preserved during
the preparation of the distal humerus. They act as
Figure 7.13 Rasping points of reference to ensure satisfactory
the humeral canal orientation and alignment. The trial prosthesis is
inserted until the margins of the prosthesis are
exactly level with the epicondylar articular
surface margin on the capitellar and trochlear
sides (Fig. 7.14). Further small pieces of bone are
removed with rongeurs or bone nibblers from the
distal humerus to aid proper seating of the
component.
A high-speed burr is used at an angle of roughly
Figure 7.14 Trial of the 55° from the vertical in a posterior and distal
humeral component direction to remove subchondral bone to identify
the ulnar medullary canal. Serial rasps are
Radial head replacement 89
Closure
Figure 7.15 Rasping of the ulnar metaphysic
As for elbow arthrolysis.
PREOPERATIVE PLANNING
Indications
• Valgus instability (due to medial collateral
ligament instability) with type III radial head
Figure 7.16 Implanted components fractures
90 Surgery of the elbow
• Radial head fracture with distal radioulnar joint move the fingers distally until a depression is felt.
instability (Essex–Lopresti injury). The radial head lies within a palpable depression
distal to the lateral epicondyle. On pronating and
Contraindications supinating the forearm, it can be felt to move.
Operative planning
Triceps
Anteroposterior and lateral radiographs, less than brachi
6 months old, should be available. Availability of Extensor carpi
Anconeus
ulnaris Olecranon
the implants must be checked by the surgeon:
• Silicone replacement – can be used as a Figure 7.17 The incision and surface anatomy of the
temporary spacer (uncemented) lateral approach to the radial head
• Vitallium prosthesis – provides more stability
than silicone replacement and does not cause
synovitis. Need to be careful not to ‘overstuff’ Dissection
the joint as this can lead to pain and loss of
extension (cemented or uncemented).
Structures at risk
Anaesthesia and positioning
• Radial nerve
See ‘Elbow arthrolysis’ (p. 80). • Posterior interosseous nerve (PIN)
SURGICAL TECHNIQUE
The incision is continued through subcutaneous
There are two options. The distal dissection for fat and through the fascia between triceps and
the proximal radioulnar joint as described for the origins of the extensor carpi radialis longus
trans-tricipital approach (see ‘Elbow arthrolysis’, (ECRL) and brachioradialis. An interval is
p. 83) or the lateral column approach as described developed between the triceps posteriorly and the
below. origins of ECRL and brachioradialis anteriorly. In
the proximal end of the wound, the radial nerve
LATERAL APPROACH (MORREY) must be avoided in the interval between the
brachialis and brachioradialis muscles. The
Landmarks common origin of the extensor muscles is
removed from the lateral epicondyle together
The lateral epicondyle, radial head and tip of the with a thin flake of bone, using a small osteotome.
olecranon. Palpate the lateral epicondyle and Reflecting the common origin distally exposes the
Radial head replacement 91
Lateral
epicondyle Brachioradialis
Biceps Common
tendon extensor origin
Triceps
Posterior
interosseous
nerve
Supinator
Capitellum
Anconeus
Forearm Forearm
pronated Supinator
supinated
Annular Radial head
ligament
Figure 7.18 Anatomy of the posterior interosseous Figure 7.19 Lateral approach
nerve
radiohumeral joint. The PIN is vulnerable as it radial head trial should be chosen to match the
enters supinator and must be protected (Fig. diameter of the articulation surface of the native
7.18). radial head. If the radial head diameter is between
The origins of the brachioradialis and ECRL two available sizes, the smaller of the two radial
muscles are elevated subperiosteally and the
capsule incised to expose the lateral aspect of the
elbow joint. By incising the capsule anterior to the
radial humeral ligamentous complex, (overlying
the radial head) in line with the radius, the lateral
collateral ligament is avoided. However, the
incision must not stray too far anteriorly as the
radial nerve runs over the anterolateral portion of
the elbow capsule (Fig. 7.19).
The annular ligament is incised longitudinally
before transecting the radial neck with an
oscillating saw using a radial cutting jig (Fig. 7.20).
Exposure distal to the annular ligament risks
damaging the PIN and is avoided. The cut surface
of the proximal radius should be smooth and
even, so that contact between it and the collar of
the prosthesis is complete.
The proximal radial medullary canal is prepared
with burs or rasps to accept the implant stem. The Figure 7.20 The radial neck cut
92 Surgery of the elbow
RECOMMENDED REFERENCE
Ates Y, Atlihan D, Yildirim H. Current concepts in
the treatment of fractures of the radial head, the
olecranon, and the coronoid. J Bone Jt Surg Am
1996;78:969
SURGICAL TECHNIQUE
Extensor carpi
Extensor origin release (tennis elbow) radialis brevis Extensor carpi
degeneration radialis longus
Landmark
The lateral epicondyle.
Lateral
Incision epicondyle Extensor
aponeurosis
A 4–5 cm gently curved skin incision is made
centred over the lateral epicondyle (Fig. 7.22).
Resection
Superficial dissection brevis
The incision is continued through subcutaneous Synovial
fat and down to fascia. The fascia overlying the opening
posterior edge of the ECRL is incised and elevated
to expose the extensor carpi radialis brevis
(ECRB), which lies beneath the ECRL. Just Lateral
epicondyle Aponeurosis
Decortication
anterior lateral
condyle
Epicondyle
Proximal anterolateral
portal
Posterior
antebrachial
cutaneous nerve
Lateral
epicondyle
Radial nerve
Mid-lateral
portal
Lateral Midanterolateral
antebrachial portal
cutaneous
nerve Anterolateral
portal
Figure 7.25 Lateral elbow arthroscopy portals
The proximal anteromedial portal The posterior antebrachial or lateral brachial nerves
can be damaged with deep incisions.
Structures at risk
• Median nerve This is 3 cm proximal to the olecranon tip and just
lateral to the border of the triceps tendon.
Elbow aspiration/injection 97
The direct posterior portal the radioulnar and radiocapitellar articulations plus
the annular ligament. Extending the elbow reveals
Structure at risk more of the capitellum and forearm rotation
exposes more of the radial head. The anterolateral
The ulnar nerve, if placed too medially. gutter and capsule should also be examined.
Next, the direct lateral portal is established. Via
this portal, the radial head (concave) is viewed,
This is 3 cm proximal to the olecranon tip and
articulating with the capitellum (convex). The
2 cm medial to the posterolateral portal. It is
articulation between the olecranon and the
established under direct vision with the
trochlea is also well seen.
arthroscope in the direct lateral portal (Fig. 7.26).
Finally, through the posterolateral portal, the
olecranon fossa, olecranon tip and posterior
Procedure trochlea are examined. Loose bodies and
osteophytes are sought, particularly on the
A systematic approach is essential if pathology is
olecranon tip.
not to be missed. About 15–25 mL of fluid is
Specific instruments can be used for removal of
instilled into the joint, to distend the capsule,
loose bodies or debridement.
through the direct lateral portal using an 18G
needle. Backflow of fluid confirms correct
placement. The anterolateral portal is established Closure
(see above) and the arthroscope and cannula
Non-absorbable suture is used to close the skin
inserted. The capsule medial to the articulation is
defects. Occlusive dressings are applied. Wool and
examined first. Medial laxity can be assessed by
crepe bandage pressure dressing is used.
supinating the forearm and applying valgus stress
to the elbow in varying degrees of flexion. Flexing
POSTOPERATIVE CARE AND
and extending the elbow allows the trochlear to INSTRUCTIONS
be viewed. The radioulnar articulation is observed
as the forearm is rotated and, for coronoid The pressure dressing is removed at 48 hours. The
impingement, as the elbow is fully flexed. patient mobilizes the elbow fully following a
The anteromedial portal is established under diagnostic arthroscopy.
direct vision and the arthroscope introduced to view
RECOMMENDED REFERENCE
Ulnar nerve O’Driscoll SW, Morrey BF. Arthroscopy of the
Medial antebrachial
elbow. J Bone Jt Surg Am 1992;74:84–94.
cutaneous nerve
Superomedial
portal
ELBOW ASPIRATION/INJECTION
Medial
epicondyle
Indications
Anteromedial
portal • Inflammatory arthritis and other arthropathies
Median
• Suspected infection
nerve
• Haemarthrosis.
Brachial
artery
Consent and risks
• Nerve injury: 1 per cent
• Infection: 1–2 per cent in osteoarthritis,
5 per cent in rheumatoid arthritis
Figure 7.26 Medial portals in elbow arthroscopy
98 Surgery of the elbow
Approach
The elbow can be entered either ulnarly or
radially, but the radial approach is preferred in
Lateral epicondyle
order to avoid ulnar nerve injury
Radial head
Landmarks
Olecranon process
Radial head, lateral epicondyle, and tip of the
olecranon (anconeus triangle) (Fig. 7.27).
Procedure
Figure 7.27 Landmarks for elbow aspiration
Structure at risk
• Radial nerve
POSTOPERATIVE CARE AND
INSTRUCTIONS
The skin is prepared with a germicidal solution.
Prior to needle insertion, the elbow is flexed and An occlusive dressing is applied. Mobilization of
the forearm pronated to protect the radial nerve. the joint depends on the underlying reason for
An 18G needle is inserted into the joint, through aspiration/injection.
the soft spot at the centre of the anconeus
triangle. With this approach the needle will RECOMMENDED REFERENCE
penetrate only the anconeus and joint capsule.
If the needle hits bone, it should be withdrawn Holdsworth BJ, Clement DA, Rothwell PN.
slightly and redirected at a slightly different angle. Fractures of the radial head – the benefit of
If performing an injection, it is wise to aspirate aspiration: a prospective controlled trial. Injury
first to ensure the needle is not in a blood vessel. 1987;18:44–7.
Viva questions
1. How do you approach diagnosing and the 7. What complications do you warn the patient
treatment of a painful elbow? about prior to elbow replacement? What are
their incidences?
2. What are the indications, benefits and
drawbacks for total elbow replacement? 8. What are the indications for arthrolysis?
3. How do you further investigate an elbow 9. What is your postoperative management post
replacement shown to be loose on X-ray? arthrolysis?
4. What are the treatment options for a 50-year- 10. Which approach do you use for total elbow
old man with symptomatic osteoarthritis of the replacement?
elbow?
11. What factors influence whether you use a
5. Describe the anatomy of the ulnar nerve semi-constrained or resurfacing type total
around the elbow. elbow replacement?
6. Describe the anatomy of the posterior 12. What are the contraindications to total elbow
interosseous nerve around the elbow. replacement?
Viva questions 99
13. How would you manage someone after total 18. What are the advantages/disadvantages of
elbow replacement? radial head replacement versus radial head
excision?
14. Which nerves can be injured in elbow surgery?
19. What approach would you use for a radial
15. What factors contribute to loosening in total
head replacement?
elbow replacement?
20. What are the complications associated with
16. Describe the portals used in elbow arthroscopy.
radial head replacement?
17. What structures are at risk from each portal?
8
Surgery of the wrist
James Donaldson and Nicholas Goddard
TH
STT
Ulnar
Radial midcarpal
1–2 6U
midcarpal
3–4 6R
4–5
• The 3–4 portal is between the extensor carpi according to comfort; this may depend on the
radialis longus (ECRL) and the extensor pollicis specific pathology treated.
longus (EPL), 1 cm distal to Lister’s tubercle.
This is commonly the first portal marked in RECOMMENDED REFERENCES
place and the site for injection of saline into the
wrist in order to distend the capsule. The scope Nagle DA, Benson LS. Wrist arthroscopy
is then inserted in line with the dorsal radial indications and results. Arthroscopy 1992;8:198.
slope. Warhold LG, Ruth RM. Complications of wrist
• The 4–5 portal is between extensor digitorum arthroscopy and how to prevent them. Hand Clin
communis (EDC) and extensor digiti minimi 1995;11:81.
(EDM), 1 cm distal to the DRUJ line. Whipple TL, Marotta JJ, Powell III JH. Techniques
• The 6/R portal is radial to the extensor carpi of wrist arthroscopy. Arthroscopy 1986;2:244.
ulnaris (ECU) at the level of the ulnar styloid.
• The 6/U portal is ulnar to the ECU at the level
of the ulnar styloid. WRIST ARTHRODESIS
PREOPERATIVE PLANNING
Structure at risk
• Dorsal ulnar cutaneous nerve Indications
• Post-traumatic arthritis
• The mid-carpal portal is in the scaphocapitate • Joint destruction secondary to infection or
interval, 1 cm ulnarwards and 1 cm distal to 3–4 tumour resection
portal. • Rheumatoid arthritis
• Failed arthroplasty or limited fusion
Saline (± adrenaline) are injected, to distend the • Scapholunate advanced collapse (SLAC) or
capsule, using an 18G needle at an arthroscopic scaphoid non-union advanced collapse (SNAC)
portal site. This is usually done at the 3–4 portal wrist
and with the wrist pronated and in ulnar • Spastic flexion contracture
deviation. The needle is removed and the skin • Kienbock’s disease.
incised. Blunt dissection is used to penetrate the
capsule: a small haemostat is easiest to use. The Contraindications
cannula and blunt obturator are inserted, and
inflow irrigation established. • Skeletal immaturity
• Elderly patients or sedentary lifestyle, where a
Procedure replacement may be more appropriate.
Dissection
Structures at risk
• Dorsal veins and superficial nerves – these
should be identified and protected
• Posterior interosseous nerve – see below
retracted radially, and the EDC (fourth Following measurement and tapping, a 2.7 mm
compartment) which is retracted ulnarly. Once screw is inserted. The two remaining metacarpal
the EPL is retracted, Lister’s tubercle is excised screws are inserted in a similar manner. The wrist
(using an osteotome or bone nibblers) to allow flat fusion is compressed with a 3.5 mm screw, on
plate apposition. compression mode, in the second most distal hole
The posterior interosseous nerve is identified as in the radius. The remaining three proximal radial
it enters the fourth compartment just proximal to screws are inserted with the usual method. Often
the extensor retinaculum and a 2 cm segment is a screw is inserted into the capitate through the
excised. The ECRB tendon may need to be remaining hole. Any remaining defects are filled
released off the third metacarpal for plate with bone graft and a check radiograph (Fig. 8.5)
apposition. An H-shaped capsulotomy is created is obtained.
to access the wrist joint (Fig. 8.4).
Closure
The capsule is approximated, as far as possible,
Carpal bones with Vicryl. The extensor retinaculum is closed
with Vicryl over the plate but under the extensor
tendons. Vicryl is also used to suture the fat, and
Ulna
an appropriate suture closes the skin. A volar
plaster slab is applied.
Radius
(b)
Procedure
The articular surfaces are denuded of cartilage
using rongeurs and burrs, exposing cancellous bone
in the radioscaphoid and radiolunate joints, and the
intercarpal joints (scaphocapitate, lunocapitate and
triquetrohamate). Any gaps are filled with
cancellous bone harvested from the excised bone
and distal radial metaphysis as necessary.
The precontoured plate is applied and bony
edges are contoured as necessary to allow good
apposition. The distal end of the plate should
reach the mid-shaft of the third (or occasionally
second) metacarpal. The most distal screw hole is
drilled with a 2 mm drill, in the dorsal to volar Figure 8.5 Radiographic and intraoperative views of the
direction, in the middle of the metacarpal. AO wrist fusion plate
Wrist arthrodesis 105
Incision
A ‘lazy S incision’, slightly ulnar-sided, is made on
the dorsum of the wrist.
Dissection
The extensor retinaculum is incised on the ulnar
side of the fourth compartment. The posterior
interosseous nerve is resected and an H-shaped
capsulotomy is used as in full fusion or,
alternatively, a radially based oblique flap can be
created for exposure of the joint (Fig. 8.6).
Procedure
Figure 8.6 Exposure of the carpal bones
If radioscaphoid arthrosis is present, the scaphoid
is excised, preserving the bone to be taken for later
use as cancellous graft. If unstable, the lunate can • A reamer is used to create a trough on the four
be reduced to neutral position using a K-wire as a bones, which are reamed to a depth so as not to
joystick; equally the capitate, hamate, triquetrum cause impingement dorsally
and lunate may be stabilized with volar placed K- • The articular surfaces are removed with
wires. A Spider Limited Wrist Fusion (KMI) plate rongeur or bone nibbler
(Fig. 8.7) may be used as follows: • Cancellous bone is used to pack the cavity
• Two screws are placed in each bone under • Failed conservative treatment (injection, thumb
image intensifier control. spica: success rate up to 70–80 per cent).
Other fixation methods include K-wires, staples or
headless screws. Contraindication
Dissection
Structures at risk
• Branches of superficial radial nerve – protected
by using blunt dissection
• Superficial veins Figure 8.9 First dorsal compartment
PREOPERATIVE PLANNING
Indications
• Pain relief following DRUJ disruption and
incongruity – commonly for symptomatic
malunion of Colles fractures in elderly patients Figure 8.10 Approach to the distal ulna
Ulnar shortening 109
Contraindications
Darrach
• Advanced osteoarthritis (OA) or significant
Figure 8.11 Resection and soft tissue preservation in malalignment of the DRUJ
the Darrach procedure • Relative contraindications – smokers (higher
incidence of delayed and non-union) or non-
compliant patient.
Closure
Consent and risks
Haemostasis is achieved followed by closure in
layers with Vicryl. Subcuticular or interrupted • Non-union and delayed union: 0–4 per cent with
sutures are preferred for skin closure. oblique cuts; 8–15 per cent with transverse cuts
• Prominent metalwork and tendonitis from
POSTOPERATIVE CARE AND hardware irritation necessitating removal: up to
INSTRUCTIONS 55 per cent
• Nerve damage, commonly dorsal sensory branch
A volar slab is used for 2 weeks, followed by early of the ulnar nerve: 1–2 per cent
active exercises.
110 Surgery of the wrist
Operative planning
Radiograph (90° shoulder abduction/90° elbow
flexion) of the wrist is required to estimate
amount of ulnar positive variance. The
measurement should indicate the length of
excision required to achieve a final ulnar variance
Figure 8.12 Approach between the extensor carpi
of neutral or –1 mm.
ulnaris and flexor carpi ulnaris
Figure 8.13 Surgical technique for ulnar shortening using a dynamic compression plate
Dissection Closure
The extensor retinaculum overlying the ganglion The joint capsule is left open and haemostasis
is incised. The EPL and ECRB tendons are achieved after tourniquet release. Vicryl is used to
retracted radially and EDC tendons retracted close the retinaculum and subcuticular suture to
ulnarly, exposing the ganglion. close the skin. A volar splint is applied.
SURGICAL TECHNIQUE – GANGLION OF The artery is retracted radially and the ganglion
THE SCAPHO-TRAPEZOIDAL JOINT dissected down its stalk to its origin (usually the
scapho-trapezoidal joint). The ganglion is excised
Incision with a small portion of surrounding capsule.
Viva questions
1. How many dorsal compartments are found at 10. What is the non-union rate in total wrist
the wrist and what are their contents? fusions?
2. Which nerve and artery are at risk during 11. What are the main functional disadvantages
surgical release of the first dorsal with the Darrach procedure?
compartment?
12. What alternatives are there to the Darrach
3. What is the optimal position for wrist procedure in younger and higher-demand
arthrodesis? patients?
4. Between which dorsal wrist compartments do
13. What is chronic regional pain syndrome? What
you classically approach through to access the
is the incidence after wrist or hand procedures?
wrist joint?
5. What is a ‘four corner’ fusion? 14. When should an ulnar shortening osteotomy
not be performed?
6. Name and describe the common wrist
arthroscopy portals? 15. What is the most significant factor influencing
7. Dorsal wrist ganglions usually arise from which the rate of non-union in an ulnar shortening
ligament? osteotomy?
8. What is the recurrence rate following excision 16. What is the significance of the posterior
of a volar wrist ganglion? interosseous nerve in wrist procedures?
9. Describe the radiographic features of a wrist 17. Where is the posterior interosseous nerve
with scapholunate advanced collapse. identified at the wrist?
9
Surgery of the hand
Norbert Kang, Robert Pearl and Lauren Ovens
Indications
Indications
Patients are ready for Dupuytren’s surgery if they
• Discrete Dupuytren’s cord
have a flexion deformity that is interfering with
• Metacarpophalangeal (MCP) joint flexion
their activities of daily living. Using the ‘table-top
deformity
test’ (i.e. inability to get the hand flat on the table)
• Patient unwilling or unsuitable for major
or specific degrees of flexion deformity (e.g. =30°
operative procedure
at the proximal interphalangeal [PIP] joint) as an
• Needle fasciotomy can be performed under
indication for surgery is unhelpful as they may
local anaesthesia and is particularly useful for
over- or underestimate the need for surgery.
patients who wish to avoid or are unsuitable for
general anaesthesia.
Operative planning
It is vital to record the range of movement, Contraindications
vascularity and sensation in the digits preopera-
tively so that a comparison can be made • Diffuse Dupuytren’s disease
postoperatively. • PIP joint flexion deformity – there is a
There are three common procedures: significant risk of neurovascular injury
• Fasciotomy (either open or needle) or • Patient unable or unwilling to comply with
segmental fasciotomy indefinite night-splintage with the digit in full
• Fasciectomy extension.
• Dermofasciectomy.
(a) (b)
Figure 9.1 Needle fasciotomy: (a) needling of fascia and (b) postoperative appearance
116 Surgery of the hand
Figure 9.2 Fasciectomy. (a) Skoog’s straight line incision. (b,c) Z-plasty marked out and performed
Dupuytren’s surgery 117
button-holing the skin when there is significant flex to its former position for 5–10 minutes. If this
pitting or skin involvement. Ensure that the skin fails, the surgeon can try bathing the vessels in a
flaps are thick enough to be viable (ideally just few drops of verapamil (2.5 mg/mL) or glyceryl
thicker than sub-dermal) but thin enough so that trinitrate (5 mg/mL). It is important to tell the
not too much cord tissue is left in the hand (to anaesthetist before doing this. If the vessels have
avoid recurrence). been divided, they will need to be repaired by
For fingers with significant flexion deformities someone experienced in microvascular techni-
due to a pretendinous cord, it is often helpful to ques.
carry out a fasciotomy after opening the palm.
This allows the finger to be extended and Closure
simplifies access to the rest of the digit.
Treatment of any skin shortage in the digit
requires closure of the skin with a Z-plasty. The
Procedure
ideal Z-plasty for closure has a 30° angle and is as
large as possible. It is not necessary to locate the
transverse limb of the Z-plasty at the flexor
Structure at risk
creases – this simply makes planning difficult.
• Neurovascular bundles Often, only one Z-plasty is required to allow
sufficient lengthening of the volar incision to
allow comfortable closure. The skin of the finger is
Any longitudinal cord tissue should now be closed with interrupted or continuous absorbable
excised, leaving the transverse fibres of the palmar sutures (e.g. 5/0 Vicryl rapide).
aponeurosis in place where possible. The The transverse palmar incision should be left
neurovascular bundles should be visualized in the open. If the maximum width of this incision does
palm on either side of the flexor tendon. The rest not exceed 1.5 cm it will heal by secondary
of the dissection is directed at freeing the intention within 2 weeks. Leaving the palm open
neurovascular bundles from the cord tissue on also simplifies closure of the hand and reduces the
both sides of the finger by a combination of blunt risk of a haematoma by allowing free drainage
and sharp dissection. Once both bundles have from the dissected areas.
been skeletonized as far as the DIP joint, any soft
tissues remaining between the skin and the tendon
Postoperative care and instructions
sheath can be excised and discarded.
Any remaining flexion deformity must now be All patients undergoing fasciectomy should be
assessed (e.g. from a boutonnière deformity at the allowed to mobilize their digits freely after
PIP joint, volar plate contracture, shortening of treatment unless they have a significant
the flexor sheath or volar skin shortage). In many boutonnière deformity and/or needed significant
cases, it is due to a combination of all of these manipulation/release of the PIP joint
factors. Boutonnière deformities respond well to intraoperatively. This latter group of patients
splintage in full extension for 1 week. Volar plate should be splinted continuously in full extension
contractures require either passive manipulation for 1 week. Thereafter, all patients must use a
of the PIP joint or sharp release of the volar splint at night for 3 months to keep the treated
plate/check-rein ligaments. digit(s) in full extension.
‘White fingers’ need to be detected. The
tourniquet must be released before beginning DERMOFASCIECTOMY
closure to check perfusion of the digit and carry
out haemostasis. If the finger fails to perfuse, then This is a fasciectomy with excision of the
both vessels need to be visualized to ensure that proximal digital skin. The aim is to excise all the
they are in continuity. You only need one intact soft tissues except the tendon/tendon sheath and
artery to perfuse the digit. If the vessels are intact the neurovascular bundles on the volar side of the
but the digit is still white, the digit is allowed to proximal part of the finger. The resulting defect is
118 Surgery of the hand
then resurfaced with a full-thickness skin graft. for a fasciectomy (p. 116). Then a full-thickness
The aim is to remove any tissue that may result in graft of appropriate size is harvested from the
subsequent recurrence of a longitudinal cord volar forearm or groin and secured to the finger with 4/0
to the axis of flexion of the digit. or 5/0 Vicryl rapide. The authors’ preferred
approach is to anchor the four corners of the graft
Indications and then secure all the edges of the graft with a
continuous over and over suture of 5/0 Vicryl
As for fasciectomy (p. 115) but with added rapide. The middle of the graft is then secured to
indications: the tendon sheath with two or three quilting
• Recurrent disease sutures of 5/0 Vicryl rapide to reduce the tendency
• Severe diathesis for the graft to slide around. This improves the take
• Extensive skin involvement. of the graft and reduces haematoma formation.
Surgical technique
As for fasciectomy (p. 116). The neurovascular
bundles must be freed from all the soft tissues and
skeletonized from the palm to the fingertip. After
excising all the soft tissues between the skin and
the tendon sheath, the skin on the volar side of the
proximal segment of the finger is also excised
down to the mid-lateral line (Fig. 9.3).
Correction of the flexion deformity is now Figure 9.3 (a) Dermofasciectomy of little and ring
checked as for a fasciectomy (p. 116). Haemostasis fingers and (b) 3 months postoperatively with healed
and perfusion of the digit are also now checked as graft
Synovial cyst treatment 119
Proximal interphalangeal joint are used for the DIP joint are also suitable for the
A longitudinal split in the extensor tendon or a PIP joint. The authors’ preference is to use a
Chamay approach (distally based ‘V’ shaped tension band technique.
incision in the central slip; Fig. 9.7) can be used to
expose the PIP joint. The joint is disarticulated by Metacarpophalangeal joint of the thumb
excising the collaterals and detaching the volar The joint is exposed through a longitudinal split in
plate. The joint surfaces are removed with a saw or the extensor tendon and disarticulated by excising
a bone nibbler to create two flat surfaces with the the collateral ligaments and detaching the volar
correct angulation (Table 9.1). plate. The joint surfaces are excised. The authors’
As for the DIP joint, there is no preferred preference for arthrodesis of the thumb MCP
method for fixation. Any of the techniques which joint is a tension band wire technique.
Figure 9.7
(a) Chamay approach.
(a) (b) (b) Longitudinal split
124 Surgery of the hand
tighter the intrinsics, the more bone that needs to bands. To reach the joint, the central slip of the
be excised (up to a limit – excessive shortening is extensor tendon can be split longitudinally or a
best avoided). The base of the proximal phalanx is Chamay approach used (see Fig. 9.7). It is
not excised unless there is severe deformity. important to preserve the central slip insertion
However, any osteophytes must be removed with whichever method is used.
bone nibblers since these may interfere with flexion. As with the MCP joint, the capsule of the PIP
The base of the proximal phalanx is now pierced joint is usually very flimsy and excised together
with an awl. This opening is enlarged and the with any associated synovium. If possible, the
medullary cavities of the proximal phalanx and collateral ligaments and volar plate are preserved
metacarpal are now reamed by hand using to maintain the stability of the joint. However,
progressively larger reamers. Sizers are used to sometimes these structures are grossly damaged
determine the correct size of Swanson’s implant and it is necessary to excise/detach them to
which should be used. In general, the largest restore the correct alignment of the proximal and
implant that fits should be selected. The implant fits middle phalanges.
when the long stem fits snugly in the metacarpal
and the short stem fits snugly in the proximal Procedure
phalanx. There should be no compression of the
mid-section with the fingers in extension. Generally, Structure at risk
size 3 or 4 implants are used for the MCP joints.
The sizer is removed and the wound is washed • Flexor tendon
out with saline. The appropriate permanent
implant is inserted using a ‘no touch’ technique.
The head of the proximal phalanx is now excised,
The implants are usually supplied with stainless
at neutral, using an oscillating saw. Care is taken
steel ‘grommets’. These should not be used.
not to damage the flexor tendon on the volar side
Closure of the joint. The base of the middle phalanx is not
normally resected except in severe deformity.
It is not necessary to formally repair the collateral
However, osteophytes must be nibbled away as
ligaments – scar tissue forms rapidly around the
these may interfere with flexion. Sizing and
implant and confers some stability to the joint.
reaming of the middle and proximal phalanges is
The sagittal bands are repaired with 4/0 or 5/0
performed in the same way as for the MCP joint.
PDS and are reefed as necessary if there is
For the PIP joint a size 1 or 2 implant is usually
significant subluxation of the extensor tendons
used.
into the ulnar gutters.
The skin is then closed with absorbable sutures.
The author recommends using interrupted 5/0 Closure
Monocryl for the dermis (to approximate the
The longitudinal split in the extensor tendon or
wound edges) then a running subcuticular 5/0
the Chamay flap is repaired with a continuous 4/0
Monocryl suture for final closure.
or 5/0 PDS suture. In all other respects, closure is
the same as described for MCJ arthroplasty.
PROXIMAL INTERPHALANGEAL JOINT
Landmarks and incision POSTOPERATIVE CARE AND
INSTRUCTIONS
A longitudinal incision (straight or curvilinear) is
made over the dorsum of the joint. • MCP joint: Patients are placed in a resting splint
or bulky bandage for 3–5 days. This is then
Dissection replaced with alternate-day flexion (MCP joints
After the incision is made, the skin and at 70–90°) and then extension (MCP joint at
subcutaneous fat are widely degloved over the neutral) splints for 24-hour periods. After 4
joint to expose the extensor tendon and the lateral weeks these splints are worn at night only and
Extensor tendon repair 127
• Zone 2 – injuries to the extensor apparatus in • Delayed presentation (more than 6–8 weeks) of
zone 2 result in a mallet deformity and are extensor ruptures in zone 6, 7 and 8 can rarely
treated as for injuries in zone 1. be repaired primarily because the tendon ends
• Zone 3 – injury to the central slip results in a will have retracted and shortened
boutonnière deformity and is often a late • Attrition ruptures – tendon grafts or transfers
presentation. If this is an open injury and the are required and may or may not be possible
damage to the central slip is recognized acutely, • Smoker
then it is worth considering surgical reinsertion • Poor social or psychological circumstances.
of the central slip. The lack of soft tissue for Patients who do not understand their injury and
reattachment means a mini-Mitek bone anchor cannot/do not comply with the hand therapy
or a ‘washing-line’ will need to be used to that is required after a tendon injury seldom
suture the tendon to the bone (see below for regain full function of the affected part. This
details of the surgical technique). Even if the often includes very young children
central slip is reinserted surgically, the patient • If there is 20 per cent (or less) division or loss of
will need the same splintage and hand therapy the extensor apparatus at any level then the
postoperatively as for a closed injury. Therefore, skin should be closed and the tendon injury
there is a strong argument for not doing ignored.
anything other than closing the skin as in zones
1 and 2. If the presentation is delayed or
chronic, the PIP joint is statically splinted in full Consent and risks
extension for 3 weeks followed by treatment • Scars: it is often necessary to extend the wounds
with a Capener (dynamic) splint for another 3 to gain access to the tendon ends
weeks. Only if this fails should surgery be • Splintage and physiotherapy: the patient will not
considered to reinsert/reef the central slip have full use of the affected hand for 8–10
and/or to mobilize the lateral bands which will weeks. This may have significant economic
have slipped volar to the axis of movement of consequences. The importance of compliance
the PIP joint. with the postoperative physiotherapy must be
• Zone 4 – injuries in zone 4 behave like injuries stressed
in zone 3. However, there is now sufficient • Infection
tendon material to consider surgical repair • Rupture: 5 per cent
using interrupted horizontal mattress sutures of • Adhesions: a particular problem if there is an
4/0 PDS. underlying fracture.
• Zone 5 – injuries in zone 5 result in an extensor • Bowstringing: in zone 7 injuries
lag which can be very debilitating. Patients
usually do very well after surgical repair of the
tendons in this zone followed by early active Anaesthesia and positioning
mobilization (see below for mobilization
regimen). For finger injuries up to zone 5, a ring block is
• Zones 6–8 – in these zones, the extensor sufficient. For more proximal injuries, in zones 6–
tendons are more rounded, making a surgical 8, a general anaesthesia or regional block is used.
repair much easier. Positioning is supine with an arm table and a
tourniquet appropriate to the part affected.
Contraindications
SURGICAL TECHNIQUE
• Active infection – the repair will rupture and
the tendon will become adherent Landmarks and incisions
• Skeletal instability – unstable fractures must be
fixed at the same time as any tendon repair If there is a skin laceration over the injured
• Fixed joints extensor tendon then it can be incorporated into
Extensor tendon repair 129
any incision after suitable debridement of the The PIP joint is fully extended and the central
wound edges. Incisions are extended proximally slip secured with the two strands of suture.
and distally as needed to gain access to the tendon Alternatively, a 0.35–0.45 gauge dental wire is
ends. This is particularly necessary in zones 6, 7 inserted across the base of the middle phalanx.
and 8 where the proximal ends may have The wire is formed into a loop close to the
retracted a considerable distance. bone, leaving enough of a gap to allow the
‘Zig-zag’ or ‘lazy-S’ incisions are preferred as passage of multiple sutures under the wire. The
these heal better when making long incisions over whole wire now acts as a suture anchor
the dorsum of the hand and wrist. allowing multiple sutures to be passed into the
central slip and under the ‘washing line’.
Dissection • Zones 4 and 5 – the extensor tendon is flat, so
horizontal mattress sutures using 5/0 or 4/0
PDS are best for the repair. The repair is
Structures at risk augmented with a continuous, over and over
suture of 5/0 PDS to keep the tendon ends tidy
• Edges of the skin flaps (Fig. 9.11). In zone 5, any lacerations to the
• Dorsal veins and nerves sagittal bands must be repaired with 5/0 PDS to
prevent the extensor tendon subluxing into the
radial or ulnar gutters.
Skin and subcutaneous fat are incised and then
• Zones 6–8 – the ends of the tendon are
skin flaps are elevated. These can be retracted with
minimally trimmed and repaired with a
skin hooks or held in place with ‘stay’ sutures. The
modified Kessler core suture, using a 3/0 or 4/0
dorsal veins and nerves are always preserved
PDS. If necessary, the core suture can be further
where possible.
augmented with a single horizontal mattress
The extensor tendons are identified and care is
suture of 4/0 PDS. A continuous epitendinous
taken to preserve the paratenon.
suture is then placed around the circumference
of the repair using 5/0 or 6/0 PDS (Fig. 9.12).
Procedure
• Zones 1 and 2 – the tendon injury is treated
non-operatively.
• Zone 3 – where appropriate, the central slip can
be reinserted using a mini-Mitek anchor or a
‘washing-line’ (Fig. 9.10). Two mini-Miteks are
inserted into the base of the middle phalanx.
Mini-Mitek
‘Washing-line’
(0.35–0.45 gauge dental wire)
Figure 9.10. Reinserting the central slip with mini-Mite Figure 9.11 Repair of an extensor tendon in zones 4
anchors or a ‘washing line’ and 5
130 Surgery of the hand
Closure
(c) The tourniquet is released and haemostasis
achieved. The wound is washed out with saline
Figure 9.12 Zones 6–8 extensor tendon repair. (a)
and closed with interrupted absorbable 4/0 or 5/0
Kessler stitch, (b) epitendinous suture and (c)
augmentation with a horizontal mattress suture
Monocryl sutures and a subcuticular 5/0
Monocryl suture. Interrupted, non-absorbable
sutures are avoided on the dorsum of the hand
and fingers as this leaves very unsightly suture
This also augments the repair and helps to keep marks.
the tendon ends tidy. A round-bodied needle is Mepitel is applied to the wound together with
preferred for both core and epitendinous dressing gauze and Velband before placing the
sutures to reduce the chance of cutting the core hand and forearm in a volar slab plaster of Paris
suture accidentally. with the fingers in full extension. The plaster
should be set before the patient comes off the
If a primary repair of the extensor tendon cannot operating table.
be performed (e.g. delayed presentation or loss of
tendon substance) an interposition tendon graft or
POSTOPERATIVE CARE AND
tendon transfer must be used, e.g. with palmaris
INSTRUCTIONS
longus tendon. A Pulvertaft weave (Fig. 9.13)
must be used to secure the tendon graft to the The authors use the Norwich regimen for injuries
ends of the tendon as this is strong enough to in zones 5–7. The plaster of Paris is replaced with
allow early mobilization. a thermoplastic splint the day after surgery.
Passive and active extension is commenced
straight away, protected in the splint for 4 weeks.
For a further 4 weeks, the patient removes the
splint for active extension and active flexion of the
IP joint/MCP joint, but wears it at all other times.
For central slip injuries (zones 3 to 4) the finger
is placed in a cylinder splint (PIP joint static in
extension, DIP joint free) for 3 weeks and then 3
further weeks in a Capener splint.
RECOMMENDED REFERENCES
Abouna JM, Brown H. The treatment of mallet
finger. The results in a series of 148 consecutive
cases and a review of the literature. Br J Surg
Figure 9.13 A Pulvertaft weave 1968;55:653.
Flexor tendon repair 131
Lange RH, Engber WD. Hyperextension mallet intervention of some form is always necessary
finger. Orthopedics 1983;6:1426. when the flexor tendons have been divided.
Newport ML, Williams CD. Biomechanical • Timing of repair – there is good evidence that
characteristics of extensor tendon suture the outcome of primary repair is superior when
techniques. J Hand Surg Am 1992;17:111. carried out as quickly as possible (within 72
Newport ML, Pollack GR, Williams CD. hours). There is a particular urgency in carrying
Biomechanical characteristics of suture out a repair of the flexor tendons (as compared
techniques in extensor zone IV. J Hand Surg Am with extensor tendons) because the flexor
1995;20:650–6. pulleys will eventually collapse/fill with scar
Stuart D. Duration of splinting after repair of tissue after 3–4 weeks. Any tendon repair will
extensor tendons in the hand. A clinical study. J then need to reconstruct the pulleys as well,
Bone Joint Surg Br 1965;47:72. making surgery more complicated than
Sylaidis P, Youatt M, Logan A. Early active necessary.
mobilization for extensor tendon injuries. The • Particular tendons – the flexor muscle bellies
Norwich regime. J Hand Surg Br 1997;22:594. (especially flexor pollicis longus – FPL) have a
Wehbé MA, Schneider L. Mallet fractures. J Bone tendency to shorten quickly. This may make
Joint Surg Am 1984;66:658. primary repair of a tendon impossible. The ring
and middle fingers are particularly prone to
avulsion injuries of the FDP tendon. Repair of
FLEXOR TENDON REPAIR combined injuries of flexor digitorum
superficialis (FDS)/FDP tendons in the little
PREOPERATIVE PLANNING and ring fingers are particularly prone to
formation of adhesions. Therefore, considera-
Indications and operative planning tion should be given to repairing just the FDP
tendon in these digits.
• Zone 1 – the technique for flexor repair in zone • Zone of injury – as for extensor tendons, the
1 depends on how close to the insertion the surgical technique for repair of flexor tendons
FDP has been divided. If the tendon is divided varies depending on the zone of injury (Fig.
close to the bone (e.g. FDP avulsion) then it 9.14).
may be necessary to use a suture anchor such as
a mini-Mitek to secure the tendon end.
• Zone 2 – proximal zone 1 and zone 2 repairs of
the FDP tendon are similar. The aim is to repair
the tendon but to avoid any bulkiness at the Zone 1
repair site to allow the tendon to glide within (distal to
FDS insertion)
the flexor sheath. If the repair is done badly it
will be too bulky and may trigger, rupture or
Zone 2
jam in position unless the flexor sheath is (A1 to FDS
opened. Special care must be taken with repairs insertion)
of FDS in this zone (see below).
• Zone 3 – zone 3 repairs are easier to perform Zone 3
because there is no tight flexor sheath to (palm)
contend with and the tendon ends are larger.
Distal zone 3 repairs may catch on the A1 Zone 4
pulley, which may need to be divided. (carpal tunnel)
• Zones 4–5 – repairs in these zones are the same
Zone 3
as repairs of the extensor tendons in zones 6–8. (forearm)
• Complete division – primary repair of a flexor
tendon rupture should be performed as soon as Figure 9.14 The zones of flexor tendon injury. FDS,
possible. Unlike the extensor tendons, surgical flexor digitorum superficialis
132 Surgery of the hand
The flaps can be retracted with skin hooks or held Flexor digitorum superficialis distal to the
in place with ‘stay’ sutures. A ‘window’ is opened metacarpophalangeal joint
in the flexor sheath by creating zigzag flaps. If the FDS is injured where it is beginning to
Ideally, the window should be as small as possible flatten out or after it has split into its two terminal
and should be positioned only between the slips, then horizontal mattress sutures must be
annular pulleys to allow maximum preservation of used to repair the tendon because there will not
the pulley system. be enough tendon substance for a modified
If the flexor sheath is opened with zigzag flaps Kessler core suture. Each terminal slip must be
it is usually possible to repair the sheath with a repaired separately. If there is room for it, an
slightly larger diameter by approximating the tips epitendinous suture using 5/0 or 6/0 PDS can be
of the flaps. This will allow any reconstructed used to tidy the ends of the repair. Note that in
pulley system to accommodate a more bulky, less combined FDS/FDP injuries of the little and ring
than perfect, tendon repair. fingers there is an argument for not repairing the
FDS tendon to avoid creating two bulky tendon
Procedure repairs, both of which will be unable to glide in
the flexor sheath.
Tendon retrieval
FDP, FPL and FDS proximal to the
If a tendon has been fully divided, flexion of the
finger or thumb normally delivers the distal end metacarpophalangeal joint
into the wound. If the proximal end of the tendon The tendon ends are approximated and held in
has retracted it can sometimes be retrieved by position by transfixing them with a 20G needle.
passing a small curved artery clip into the flexor The ends of the tendon are minimally trimmed
sheath. If this proves impossible, then the palm of and the back wall of the repair is begun with a
the hand must be opened and the tendons pushed continuous 5/0 or 6/0 PDS over and over suture.
up into the finger with forceps. If the laceration is A modified Kessler core suture is now inserted
in the wrist or palm, it may be necessary to extend using 4/0 or 3/0 PDS, taking particular care to
incisions even more proximally to find the tendon bury the knot. The core suture can now be
ends. Once retrieved, a 20G (blue-hub) needle augmented with a single horizontal mattress
can be passed through the tendon ends to prevent suture using 4/0 PDS. The anterior part of the
them from retracting again until the repair is epitendinous suture is then completed (Fig. 9.16).
complete. The core suture should always be over-tightened
to prevent gaping when early active mobilization
Tendon suture technique is started postoperatively. A round-bodied needle
Zone 1 – If there is a very short stump of tendon should also be used to reduce the risk of cutting
(<1 cm), then it is possible to repair the tendon by the core suture accidentally. There must be no
inserting 4/0 or 5/0 PDS sutures as a half-Kessler gaping of the repair and it must glide freely
proximally and horizontal mattress distally. through the full excursion of the tendon when the
Multiple sutures can be inserted to increase the repair is complete. Any pulleys restricting the
strength of the repair since there is no concern glide of the tendon should be divided in a zigzag
about the bulk of the repair getting caught in fashion or excised altogether.
the flexor sheath. When the tendon is avulsed
and/or there is a fracture of the distal phalanx, Closure
then alternative methods of fixation must be
considered, e.g. suture the tendon to the All wounds are washed out with saline and closed
remnants of the periosteum or use a suture with interrupted absorbable 4/0 or 5/0 Vicryl rapide
anchor such as two mini-Miteks. If there is a sutures. Unlike the dorsum of the hand, suture
fracture, then mini-plate fixation is the best option marks are not so much of a problem on the volar
to repair the fracture, using the plate as a suture side because of the thicker epidermis. Therefore,
anchor. subcuticular sutures do not have to be used.
134 Surgery of the hand
Mepitel, dressing gauze and Velband bandage Silfverskiold KL, Anderson CH. Two new
are applied and the hand and forearm are placed methods of tendon repair: an in vitro evaluation of
in a dorsal plaster of Paris with the fingers flexed tensile strength and gap formation. J Hand Surg
at 90° at the MCP joint and the wrist in neutral. Am 1993;18:58–65.
The plaster should be set before the patient comes Sirotakova M, Elliott D. Early active mobilization
off the operating table. of primary repairs of the flexor pollicis longus
tendon with two Kessler two strand core sutures
POSTOPERATIVE CARE AND and a strengthened circumferential suture. J Hand
INSTRUCTIONS Surg Br 2004;29:531–5.
Small JO, Brennan MD, Colville J. Early active
Early active mobilization begins on day 1 mobilisation following flexor tendon repair on
following the Belfast regimen. The plaster of Paris Zone 2. J Hand Surg Br 1989;14:383–91.
is replaced with a thermoplastic splint the
following day. Full passive flexion is commenced
in all digits. The repaired tendon is allowed to
commence immediate, controlled, active flexion TENDON TRANSFERS
and extension.
All exercises are performed in the splint for the PREOPERATIVE PLANNING
first 4 weeks. After 4 weeks, the patient can
remove the splint, but only to do exercises. At all Tendon transfers are useful to restore hand
other times, the splint remains in place. No passive function in patients where a primary tendon
extension is permitted for 8 weeks. repair is difficult or impossible. The essence of a
good transfer is to keep it simple and to plan
RECOMMENDED REFERENCES carefully. The authors recommend listing all
functions (absent and present) to allow
Kessler I, Nissim F. Primary repair without formulation of a plan. An example is given in
immobilization of flexor tendon division within Table 9.3.
the digital sheet. Acta Orthop Scand 1969;40:587–
601. Indications
Kleinert HE, Kutz JE, Ashbell TS, et al. Primary
repair of lacerated flexor tendons in ‘No Man’s • Nerve palsies – Tendon transfers are particularly
Land’. Proceedings, American Society for Surgery useful for isolated nerve palsies. For a transfer
of the Hand. J Bone Joint Surg Am 1967;49:577. to be possible, the hand or upper limb must
Tendon transfers 135
have sufficient numbers of functioning tendons • Before 9–12 months have elapsed after any
which can be used for the transfer without motor nerve repair. If motor recovery has not
adversely affecting overall hand function. occurred by this time, then it is very unlikely to
Therefore, patients with a global loss of nerve occur and a tendon transfer is justified
function (e.g. cerebral palsy) will always do less • Where other procedures would be more
well. beneficial, e.g. for delayed presentation of an
• Delayed presentation of tendon rupture – FDP laceration or avulsion, a tendon graft or an
Tendon transfers may be necessary to restore arthrodesis of the DIP joint may be the
function even in delayed presentations because preferred options. Similarly, a flexor rupture in
of shortening of the muscle bellies after zones 1 and 2 for patients with rheumatoid
rupture. arthritis is usually best treated with a tendon
graft.
Contraindications
Consent and risks
• If the joint which the tendon is intended to
move is not fully supple • Donor site morbidity: patients may experience
• If the part of the hand/upper limb which is to weakness or some loss of function after harvest
be moved by the tendon is not fully sensate of a tendon. For example, after harvest of the
• If the tissue bed through which the transfer will extensor indicis proprius (EIP), patients may
pass is poorly vascularized and/or heavily experience an extensor lag at the index finger
scarred (e.g. under a skin graft) MCP joint
• If the transfer results in loss of an essential • Additional scarring: after harvest of the
function tendons/grafts
• If the power of the transferred muscle is less • Rupture: this is a particular risk if a Pulvertaft
than 5 (Medical Research Council [MRC] repair has not been used for the tenorrhaphy
grade). This is because any transferred muscle and/or when an interposition, free tendon graft
loses at least 1 grade after the transfer has been used to lengthen any donor tendon
• If the amplitude of the transferred muscle is not (resulting in two tendon repairs)
similar to the muscle that it is replacing. For • Patients must be warned of the prolonged
example, finger flexors have an excursion of rehabilitation that must be followed after any
about 70 mm. Wrist extensors/flexors have an tendon transfer (8–12 weeks) during which they
excursion of only 30–40 mm. This is not a good will be unable to use their hand normally
match
136 Surgery of the hand
Closure
SOFT TISSUE RECONSTRUCTION
All wounds are closed in layers with absorbable
sutures using interrupted 4/0 or 5/0 Monocryl to PREOPERATIVE PLANNING
dermis and 4/0 or 5/0 Vicryl rapide as a
For the purposes of this handbook, the focus is on
subcuticular stitch. Mepitel, dressing, gauze and
three areas:
Velband bandage are applied as needed and the
• The operative correction of aberrant scarring
hand and forearm are placed in a resting volar
• The use of split thickness skin grafts
plaster. The plaster should be set before the
• The use of full thickness skin grafts
patient wakes up.
Figure 9.17 Soft tissue reconstruction needed for (a) skin loss after sepsis, (b) burns or (c) a poor volar scar
138 Surgery of the hand
• Smoking. Expect a 40 per cent increase in where it is needed. Local anaesthesia is suitable
wound healing complications in any patient for harvesting small grafts and for surgery to the
who smokes digits. However, patients may be more grateful for
• Long term steroid use. Particularly in a general anaesthetic when harvesting large grafts
rheumatoid arthritis (relative contraindication) and operating on multiple areas (e.g. harvest a
• Peripheral vascular disease or similar e.g. FTG from the groin for use in the hand) and on
Buerger disease, scleroderma or severe Raynaud the palm of the hand. The hand is placed in the
• Previous radiotherapy to the hand supine position on an arm table. A tourniquet is
• Recipient site unsuitable. Grafts will not take essential for any surgery involving the use of flaps
on bare bone or tendon unless these areas are or grafts in the hand.
very small (<5 mm diameter) in which case the
grafts can survive by ‘bridging’ SURGICAL TECHNIQUE
• Donor site problems.
Z-plasty is used when there is a need to change
the direction and/or length of a scar. The best
Consent and risks example of its use is to correct a webbed volar
scar. Z-plasty can also be used to lengthen a scar
• Scarring: particularly with split skin grafting
after Dupuytren’s fasciectomy (see Fig. 9.2,
which leaves large, unsightly scars
p. 116).
• Infection
• Flap necrosis: this is nearly always the result of
technical error (e.g. flaps too narrow, closure too Landmarks and incisions
tight) but may also be a consequence of
In most cases, a 30° or 60° angle is used for the flap
infection
design. A 60° angle achieves more lengthening of
• Graft loss
the scar but a 30° angle is often easier to transpose.
• Prolonged healing: a split skin graft (SSG) donor
The width of the base of the flap in relation to its
site may take months (or even years) to heal if
length is important in determining flap survival.
the patient and donor site are poorly selected
The longer and narrower the flap, the less likely it
is to survive. The flaps are marked out as shown in
Figure 9.2 (p. 116).
Operative planning It is a myth that the limbs of the Z-plasty must
be aligned to fall in the skin creases – skin creases
There are three main techniques to master: exist because the fingers flex. When the fingers
• The Z-plasty: an operation which involves the cease to flex, the creases disappear. The Z-plasty is
transposition of two triangular skin flaps of best placed where it is needed.
equal dimension to lengthen a scar or change its
direction. There is a risk of necrosis of the flaps Superficial dissection
if they are poorly designed.
• Split thickness skin grafts: if an SSG is used, it The flaps are raised with a small amount of
is often a temporary biological dressing rather subcutaneous fat to ensure that the subdermal
than for definitive skin cover. plexus is uninjured. When raising the flaps, the
• Full thickness skin grafts (FTG): these can be underlying anatomy must be considered. For
used for definitive skin cover anywhere on the example, it is very easy to divide the neurovascular
hand except the pulps of the fingers and bundle when raising the Z-plasty flaps after a
thumb. Dupuytren’s fasciectomy.
right for the second flap before you commit on the hand knife or dermatome. Typically, the
yourself to raising it. SSG should be between 0.2 mm and 0.4 mm thick.
• If the design is right then the two flaps should The thicker the SSG, the less it will contract, but
automatically transpose themselves across the the longer it will take for the donor site to heal
scar when the finger straightens. and the more obvious the donor site scar.
• The flaps are tacked into the correct corners
and any dog-ears ignored. (These will flatten in Harvesting
a few weeks anyway.)
Liquid paraffin is applied to the skin and the knife.
Closure This acts as a lubricant and prevents the blade from
catching on the skin. If the blade catches rather
Interrupted or continuous, absorbable, 4/0 or 5/0 than cuts, it will tear the SSG or result in holes
Vicryl rapide sutures are used for closure. Do not where you do not want them. It is also critically
use non-absorbable sutures in the hand. There is important to ensure that the skin at the donor site
no difference in wound healing after skin closure is under tension. The best way to do this is to have
using absorbable and non-absorbable sutures in an assistant who can squeeze the thigh or arm
the hand. Patients find it very painful to have non- while you concentrate on harvesting the skin. A
absorbable sutures removed so avoid using them. rapid sawing motion is used to harvest the skin with
a hand-knife, keeping the blade flat with respect to
Split thickness skin grafts the skin and not pressing too hard or the graft
A small SSG (<3 cm × 3 cm) can be harvested thickness will increase. If a powered dermatome is
with a hand-held knife. However, ideally, a used, the machine does the sawing for you. The aim
powered dermatome should be used to harvest all is to harvest in one smooth action.
SSGs (Fig. 9.18). Meshing the skin increases the area which can
be covered with a given size of SSG. It also
Landmarks and incisions increases the take rate by allowing free drainage of
haematoma and seroma. It is possible to mesh skin
The first decision is the amount of SSG needed. by hand but using a skin mesher is quicker and
This is best worked out in terms of the length and neater. However, once it has taken, meshed skin
width of the defect which needs to be covered. A contracts even more than a sheet graft. An
marginally larger area than you think you will alternative is to perforate it with multiple stabs
need should always be taken (approximately 1 cm using a no. 15 blade to allow haematoma and
beyond is about right). It is easy to trim the SSG seroma to ooze through.
down to size but harvesting more graft is always a The donor site is dressed with Mefix adhesive
problem. Ensure the correct settings are selected dressing applied directly to the wound. Gauze,
(a) (b)
Figure 9.18 A Watson hand knife (a) and an air-powered dermatome (b) for harvesting split skin grafts
140 Surgery of the hand
Figure 9.19 (a) Templating, (b) marking and (c) planning incision for multiple full thickness grafts for Dupuytren’s
dermofasciectomy
Trigger finger surgery 141
scissors, to expose the flexor sheath. It is rarely In: AAOS Symposium on Tendon Surgery in the
necessary to visualize the neurovascular bundles Hand. St Louis: Mosby, 1975:81–7.
running parallel to the flexor tendons: in any case, Idler RS. Anatomy and biomechanics of the digital
these should be protected by the retractors. flexor tendons. Hand Clin 1985;1:3–11.
The proximal edge of the A1 pulley is identified
and the pulley is then divided longitudinally with
a scalpel taking particular care to stay over the
midline of the tendon to avoid the risk of damage TRIGGER THUMB SURGERY
to the neurovascular bundles.
The patient is then asked to flex and extend the
digit several times to test for any residual PREOPERATIVE PLANNING
triggering. The arm tourniquet is released, the
wound washed out with saline and haemostasis Indications
achieved.
• Persistent triggering not relieved by steroid
injections. Administer at least one, sometimes
Closure
two injections before going ahead with surgery
Skin closure is with interrupted absorbable and wait 3 months after each injection to assess
sutures. A bulky dressing is applied to the hand for outcome
24–48 hours. This can then be de-bulked by the • Locked thumb in an adult
patient to allow the fingers to flex freely. • Locked thumb in a child (usually noticed at ⬍2
years) unresolved for 肁12 months. Thirty per
cent of trigger thumbs in infants will resolve
POSTOPERATIVE CARE AND within the first year after it is noticed. Flexion
INSTRUCTIONS contractures do occur but these will correct
themselves spontaneously if the triggering
Active mobilization of the hand is commenced
resolves or if surgical release is performed
immediately. The bulky dressing should be taken
before the age of 3.
down after 24–48 hours to facilitate this.
RECOMMENDED REFERENCES
Contraindication
Doyle JR, Blythe WF. The finger flexor tendon
sheath and pulleys: anatomy and reconstruction. Presence of infection.
A1 pulley
Steroid injection around A1 pulley
reduces inflammation allowing the
nodule to pass under the pulley
Recurrence
Nodule on
Nodule on tendon
tendon Trauma to tendon Surgical release of A1 pulley
• Digital nerves and arteries – these are close to Active mobilization of the hand and thumb is
the skin in the thumb begun immediately after surgery. Heavy use of the
• Ulnar attachments of the A1 pulley – their hand is avoided for 1–2 weeks.
division may lead to bowstringing of the FPL
RECOMMENDED REFERENCE
In the thumb, the proximal border of the A1
pulley is at the level of the proximal digital skin Ger E, Kupcha P, Ger D. The management of
crease over the MCP joint. A 1–1.5 cm transverse trigger thumb in children. J Hand Surg Am
incision is created in the crease. Tenotomy scissors 1991;16:944–7.
Viva questions
1. Why perform a dermofasciectomy rather than 5. An elderly woman with rheumatoid arthritis
a fasciectomy for Dupuytren’s disease? comes to you with a painful unstable thumb
metacarpophalangeal joint. Describe your
2. How do you deal with any residual flexion of
management.
the digit after excision of all diseased
Dupuytren’s cord tissue? 6. A man of 30 with a history of psoriatic
arthropathy attends your clinic with painful
3. What are the possible complications of a
and deformed distal interphalangeal joints
fasciectomy?
affecting all fingers of both hands. How would
4. Describe a permanent solution for a painful you treat this?
distal interphalangeal joint with mucous cyst in
a 50-year-old manual worker.
144 Surgery of the hand
7. A woman of 40 attends your clinic with a and middle fingers of her dominant hand 1
history of an untreated pilon fracture of the year after a fall in the street. How would you
PIP joint of her right little finger, dominant treat this?
hand, 10 years ago. The finger is painful,
14. A 50-year-old lawyer with rheumatoid arthritis
angulated and has restricted (20–40°) active
has suddenly lost extension of his little and
flexion. What surgical options would you give
ring fingers of his non-dominant hand. What
her?
options can you offer him?
8. A 50-year-old builder attends your clinic with
15. How do you manage an isolated division of the
a painful right index finger carpometacarpal
flexor digitorum profundus tendon in the little
joint. He punched a fellow builder 5 years ago
finger of a dominant hand?
and heard a loud ‘click’ at the time. Since then,
he has experienced increasing movement at 16. Describe the operative steps involved in the
the joint associated with pain on lifting heavy repair of a combined flexor digitorum
objects. What options would you offer him? superficialis/flexor digitorum profundus tendon
injury in zone 2 of the ring finger of a 30-
9. Describe the management and treatment
year-old painter and decorator?
options for a young manual worker with a
painful, stiff, proximal interphalangeal joint 17. A patient presents with a tight volar web scar
after previous trauma with evidence of marked after Dupuytren’s fasciectomy. How would you
joint deformity on X-ray. correct this?
10. A young woman presents with a painless but 18. You have decided to carry out a correction of a
stiff index finger metacarpophalangeal joint congenital camptodactyly of the little finger.
after an infection. What surgical options would The finger is now straight but it is obvious that
you present to her? there is a shortage of skin on the volar side of
the finger which contributed to the flexion
11. Describe the surgical management of a manual
deformity in the first place. How would you
worker with a laceration in zone 6 and loss of
correct this?
extension of the thumb and index finger of his
dominant hand? 19. Describe the risks and pitfalls in the
management of trigger finger.
12. What is the management of a closed mallet
injury in a 16-year-old rugby player? 20. Describe your management of an acutely
locked trigger thumb.
13. A 60-year-old woman presents with a passively
correctible boutonnière deformity of her index
10
Surgery of the hip
Jonathan Miles and John Skinner
Position of arthrodesis
• External rotation 0–10°
• Flexion 20–25° Consent and risks
• Adduction 0–5°
• Mortality: 0.3 per cent
• Nerve injury: 1 per cent
• Infection: 1–2 per cent in osteoarthritis, 5 per
PRIMARY TOTAL HIP ARTHROPLASTY cent in rheumatoid arthritis
• Thromboembolism; deep vein thrombosis: 2 per
PREOPERATIVE PLANNING cent
• Pulmonary embolism: 1 per cent
Indications • Dislocation: 3 per cent
• Heterotopic ossification: 10 per cent (though the
Total hip arthroplasty is indicated in painful majority are asymptomatic)
conditions of the hip that have failed conservative • Limb length discrepancy: 15 per cent
management. These are too numerous to list in • Loosening: revision surgery is required for
this book but the most frequent underlying loosening in up to 10 per cent at 15 years
conditions are: • Component failure: stem fracture, locking
• Osteoarthritis mechanism failure in uncemented cups and
• Inflammatory arthritis and other arthropathies other failures of components are rare, but
• Avascular necrosis recognized, complications
• Trauma.
146 Surgery of the hip
Operative planning
Recent radiographs must be available. Templates Greater
should be routinely used to indicate the trochanter
appropriate site for the femoral neck cut and
provide a guide to implant placement and sizing.
Availability of the implants must be checked by
the surgeon.
SURGICAL TECHNIQUE
The two common approaches are the posterior
and lateral approaches.
Tendon of gluteus
Fascia lata
medius
Short external rotators
Greater trochanter
Vastus lateralis
Quadratus
femoris
Fascia lata
Superior Inferior
Greater
Lateral approach
gemellus gemellus
tronchanter
Gluteus Landmarks
Quandratus
medius
femoris • Central landmark – the greater trochanter
• The anterior superior iliac spine and the
femoral shaft are also palpable and act as useful
reference points.
Piriformis
Incision
A straight 15 cm incision is created, parallel to the
femoral shaft and centred on the anterior half of
Sciatic nerve
the greater trochanter (Fig. 10.6).
Obturator
Ischial
internus Superficial dissection
tuberosity
Figure 10.5 The path of the sciatic nerve over the The incision is continued through subcutaneous
external rotators of the hip fat and down to fascia lata. The fascia lata is
incised in line with the skin incision overlying the
lateral femur (Fig. 10.7). At this point a self-
retaining retractor is inserted.
Deep dissection
sutures (e.g. no. 2 Ethibond) are inserted into the
tendons of obturator internus and piriformis, just
Structures at risk
below their insertion into the femur, i.e. as Superior gluteal nerve – between the gluteus
anteriorly as possible. Visible vessels within the medius and minimus; this may be as close as 3 cm
operative field are coagulated: typically these lie on above the tip of the greater trochanter.
the tendon of piriformis and within the substance
of quadratus femoris. The short external rotators,
from piriformis down to gemellus inferior, are The incision continues in line with the skin
divided as close to their insertion onto the femur incision. This begins proximally within the fibres
as possible. If further room is required, the division of the gluteus medius and must be limited to a
can be carried on further distally. If the quadratus point 3 cm above the tip of the greater trochanter
femoris is divided, it should be done around 5 mm to avoid damage to the superior gluteal nerve. The
away from its insertion into the femur so that a
cuff is left to repair it back on to.
The muscles are allowed to ‘flop’ over the
sciatic nerve, providing some protection for it
throughout the rest of the operation. This exposes
the posterior capsule of the hip joint. To improve
visibility, the interval between the superior part of
the hip capsule and the gluteus minimus is
identified and dissected free with blunt dissection
or scissors. This view is maintained by inserting a
Greater
Hohmann retractor in the interval to displace the trochanter
gluteus minimus superiorly. The capsule is incised
transversely to gain access. The visible portion of
capsule can be excised or preserved and later
repaired. The visible portion of the acetabular Figure 10.6 The skin incision for the lateral approach to
labrum is excised. the hip
Primary total hip arthroplasty 149
45°
Figure 10.10 Acetabular reaming
(a) (b) 10° to 20° (a) 45° from vertical and (b) 10°–20° of
anteversion
The cemented implants also have trials, allowing quadrants. These are defined by a first line
for a cement mantle. At this point any excess passing inferiorly from the anterior superior
osteophytes around the acetabulum (that may iliac spine, through the centre of the
lead to impingement) are often apparent. These acetabulum and a second line perpendicular to
can be removed with nibblers or an osteotome. the first, again passing through the middle of
The component is inserted using the appropriate the acetabulum. This creates four quadrants
technique. It is worthwhile to ensure that the (Fig. 10.11).
pelvis has remained vertical, as any malposition of
the patient will transfer into improper angulation
of the implant, with consequent risk of instability.
Structures at risk
Technical points in uncemented cup insertion Posterior superior – the safe zone
• At risk – sciatic nerve and superior gluteal
• The uncemented cup relies on a secure fit to neurovascular bundle
confer initial stability. Posterior inferior – safe if screws < 20mm
• In the press-fit technique an implant 1–2 mm • At risk – inferior gluteal and internal pudendal
larger than the last reamer is used. This can be neurovascular bundles
augmented with screws as necessary. Anterior superior – avoid screws
• The line-to-line technique uses an implant of • At risk – external iliac vessels
the same size as the last reamer and relies on Anterior inferior – avoid screws
augmentation with screws to obtain fixation. • At risk – anterior inferior obturator
• If fixation is not solid and stable, even after neurovascular bundle
screws have been used a switch to a cemented
cup is recommended.
• Screws holes are aligned to coincide with the When all of the screws are properly seated, the
safe zone, described below. Pilot holes should liner can be inserted. The use of a 10° or 20°
be drilled, their depth ascertained with an elevated rim can be selected if using a
angled depth gauge and screws inserted with a polyethylene liner. It should be remembered that
universally jointed screwdriver and a screw this reduces the arc of motion and should not be
holder to control the direction. an automatic action. Trials are available and
• Screw augmentation, if to be used, should be should be used if there is any doubt. It is usual for
done with care and awareness of the safe the elevated lip to be situated posterosuperiorly or
152 Surgery of the hip
Safe zone
Risk: Sciatic nerve
superior gluteal
nerve and vessels
Posterior
Superior ASIS
Posterior Anterior
Inferior Superior
Anterior
Inferior Figure 10.11 The quadrants of
acetabular screw positioning. Redrawn
Risk: Anterior inferior
obturator nerve with permission from Miller (2004)
artery and vein Review of Orthopaedics. Philadelphia:
Avoid screws Saunders
more posteriorly if a posterior approach has been have a polypropylene impactor to pressurize
used. the cement into the acetabular bone.
• The surgeon should be aware of the properties
Technical points in cemented cup insertion of the cement that is being used to ensure that
• Many acetabular components have a lip the cement and component are inserted at the
augment, which should be correctly orientated appropriate time. It is vital that the component
in the posterior to superior area. If the cup has is held perfectly still while the cement is curing.
a flange (which can help to prevent cement Care should be taken to ensure that the
extrusion), this will need to be trimmed to the introducer is able to be released without undue
size of the reamed acetabulum. force, to reduce the stresses on the cement to
• Drill holes into the ilium and ischium, but not component interface.
the quadrilateral plate, and enhance the cement • Any excess cement should be removed.
fixation. The bone surface is washed with
pulsatile lavage and dried thoroughly. Many Femoral preparation
acetabular components have pegs on the medial In the posterior approach the assistant extends
surface; these are designed to ensure a uniform and internally rotates the hip while supporting the
cement mantle of around 3 mm. leg with the knee flexed. In the anterior approach,
• The cement should be introduced from a the leg is maximally adducted and the hip
cement gun with a short nozzle. It is first externally rotated; the knee is flexed to position
introduced to the keyholes in the ilium and the lower leg in the leg bag drape.
ischium. This is done with the nozzle hard An entry point is created in the proximal femur,
against the bone, to increase the pressure. It is with a box chisel, to allow the insertion of
then introduced to the rest of the acetabulum reamers; it must be correctly situated to prevent
and pressurized with an impactor: most sets varus malposition of the component. The starting
Primary total hip arthroplasty 153
provides a smooth, stable neck cut at the level • The cement gun and pressurizer are removed
upon which the collar will be supported. and the femoral component is introduced in the
• The height of the final rasp can be gauged in correct version and manually inserted to the
respect to both the greater trochanter and the correct depth. The version must remain
medial extent of the femoral neck cut. It is vital constant and the movement is a smooth, even
to be able to reproduce these relationships application of force. If the stem will not reach
with the definitive stem, when it is cemented in the desired depth with manual pressure, a
situ. mallet can be used on the introducing handle to
• Trial reduction is carried out (see below for seat the implant at the correct depth. The end
details). result should be a reproduction of the depth of
• A cement restrictor is used to occlude the the trial at time of rasping.
medullary canal distally. The depth of insertion • The implant must be held perfectly still within
is obtained by measurement against the final the femur until the cement has cured, typically
rasp used, aiming for 1–2 cm of clearance to after 10–12 minutes.
allow for distal cementing. The canal must now
be thoroughly washed with pulse lavage, using a Trialling and reduction
long nozzle to clean debris and fat from the Trial reduction is a vital step in total hip
entire length of the prepared bone. Suction is replacement (THR). The assessment is essentially
used to remove the saline cleaning solution. The of stability, range of motion and leg length.
canal is then dried and packed with swabs or a Reduction is carried out with appropriate trial
preformed absorbent sponge. components, usually consisting of the last rasp left
• Cementation is performed with a double mix of in situ and a trial head. Reduction is via the
polymethylmethacrylate cement, using a surgical assistant applying in-line traction
cement gun with a long nozzle. The cement is followed by rotation of the head into the
introduced when it is of sufficient viscosity acetabulum. The traction is assisted by the
(when the cement does not stick to the surgeon pushing on the femoral head with a
surgeon’s glove, the required viscosity has been conical pusher. If reduction cannot be achieved, a
reached – typically after around 2–3 minutes). shorter femoral head and/or a neck with less offset
• The nozzle is introduced up to the cement is selected and the manoeuvre repeated.
restrictor then cement is pumped firmly to Once the THR trial is reduced, assessment is
introduce it into the canal. The cement gun is made of the stability. The position of the head
not withdrawn, rather it is allowed to be pushed with respect to the greater trochanter is noted
out by the cement as it fills the canal. Use of and compared with that on preoperative
suction removes the fluid extruded from the templating.
canal. The hip is passed through a functional range of
• When the cement reaches the proximal femur, motion and must not dislocate in any position.
the nozzle is withdrawn and cut. A proximal The hip can then be forced into non-physiological
cement pressurizer is placed over the remaining positions to assess the point at which dislocation
nozzle and reintroduced into the femoral canal, can occur. In the lateral approach, the hip should
occluding the proximal femur. Further cement remain in joint even when the leg is replaced in
is introduced under pressure, as the restrictor adduction and external rotation, back into the
occludes the femoral cavity, for around 30 sterile ‘leg bag’. In the posterior approach, the hip
seconds. is tested in slight adduction and forced internal
• The definitive stem should be checked and rotation; the degree of internal rotation to
correctly assembled on its introducer. The dislocation should be noted and should be no less
correct time for introduction of the stem is than 40°.
determined by the type of cement and ambient The tissue tension is assessed by the ‘shuck test’
temperature conditions. It is usually at around – the femur is pulled sharply downwards and the
4–6 minutes. degree of telescoping of the femoral head away
Primary total hip arthroplasty 155
POSTOPERATIVE CARE AND in the joint after total hip or knee replacement.
INSTRUCTIONS BMJ 1982;285:10–4.
Murray DW, Carr AJ, Bulstrode CJ. Which
The patient is returned to the supine position and primary total hip replacement? J Bone Joint Surg
an abduction pillow inserted between the legs. Br 1995;77:520–7.
Any straps present on these pillows should not be Pellicci PM, Bostrom M, Poss R. Posterior
used, due to the risk of peroneal nerve damage. approach to total hip replacement using enhanced
Precautions against thromboembolism should be posterior soft tissue repair. Clin Orthop Relat Res
used. Common options include aspirin, low 1998;(355):224–8.
molecular weight heparin, graduated compression The Swedish Hip Arthroplasty Register. Online.
stockings and foot or calf intermittent Available at: www.jru.orthop.gu.se.
compression pumps. Early mobilization should be
encouraged in all patients. Two further doses of
the same antibiotic given upon induction are REVISION TOTAL HIP ARTHROPLASTY
given intravenously. Haemoglobin levels should be
monitored and transfusion considered as This section refers extensively to sections in the
necessary. primary hip arthroplasty section and is not
Weightbearing is begun immediately in those intended as a standalone text to enable all
patients with a cemented stem, regardless of the surgeons to revise all hips. It aims to provide some
cup used. Six weeks of avoidance of weightbearing useful directions as to appropriate techniques that
is recommended in many uncemented stem can be applied to solve some problems, but cannot
arthroplasties, though some are permitted early cover all potential problems.
partial or even full weightbearing. The patient is
allowed to walk but asked to avoid crossing of the PREOPERATIVE PLANNING
legs or excessive flexion of the hips. To this end,
they are provided with a raised toilet seat and Indications
instructed to avoid low seats. Particular care is
recommended when putting on socks and shoes – Revision hip replacement is indicated for painful
a common cause of early dislocation. Return to failure of a primary arthroplasty. The most
work is allowed after around 6 weeks for sedentary common causes are:
jobs, but may be delayed to 3 months or more in • Aseptic loosening of the socket and/or stem
active work. Follow-up is recommended at 6 • Deep infection (see later section)
weeks, 6 months and 1 year after surgery. • Instability, resulting in recurrent dislocation
Continuation of follow-up is typically at 5 years, • Fracture of either the implant or the proximal
10 years, 15 years and then at yearly intervals. The femur.
patient should be cautioned to return to clinic if
there is pain or functional deterioration. Contraindications
RECOMMENDED REFERENCES • Continuation of preoperative pain after hip
arthroplasty (this suggests that the original
Barrack RL, Mulroy RD Jr, Harris WH. Improved diagnosis may have been wrong and warrants
cementing techniques and femoral component further investigation).
loosening in young patients with hip arthroplasty. • Pain-free loosening is a relative contraindica-
J Bone Joint Surg Br 1992;74:385–9. tion, except in cases associated with significant
Charnley J. Arthroplasty of the hip: a new and progressive osteolysis.
operation. Lancet 1961;1:1129–32.
Hardinge K. The direct lateral approach. J Bone
Joint Surg Br 1982;64:17–9. Consent and risks
Lidwell OM, Lowbury EJ, Whyte W, et al. Effect • Nerve injury: 3–7 per cent.
of ultraclean air in operating rooms on deep sepsis
Revision total hip arthroplasty 157
Approach
Operative planning
Either the posterior or lateral approach can be
Revision arthroplasty is more challenging than used. Some surgeons argue that the posterior
primary surgery so requires even more precise approach is best for posterior acetabular defects.
planning. Recent radiographs are essential. ‘Judet A trochanteric osteotomy can be required,
views’ can be very helpful in assessing acetabular particularly in highly complex revisions or in
bone loss. If there is significant bone loss, a fine cut removal of a well-fixed cementless stem. The
computed tomography (CT) scan is used to assess greater trochanter is removed with gluteus medius
and quantify it. The patient should have been seen and minimus attached, allowing it to be mobilized
in outpatients recently so that the functional well out of the way. The length of the osteotomy
status has been noted. This is as vital as the required is dependent on the implant that you are
osseous imaging in decision making. trying to get out and may be as long as the implant
The soft tissue status must be assessed and any itself, which can be judged with image intensifier
signs of infection need investigation and treat- or from preoperative planning (Fig. 10.14).
ment. It is not always necessary to revise all com- Identification of the sciatic nerve is important,
ponents in aseptic failures; consideration should particularly in the posterior approach. The nerve
be given to keeping any well fixed and functional can be isolated by carefully passing a vascular
prosthetic component. If the prosthesis is infected, sloop around it, thus ensuring that its location is
a two-stage procedure is preferred (see below). known at all times.
Templating should be carried out with great
care. It is necessary to be prepared for unexpected
findings at the time of surgery and a wide range of
implants should be available to the surgeon.
There are a number of extra instruments which
can be useful in revision procedures. The surgeon
should consider ordering any, or all of the
following, in particular:
• Image intensifier
• Extraction instruments for the existing implant
• Bone allograft, for morcellized or block grafting
• Cement removing osteotomes and ultrasonic
cement removal systems
• Supplementary metalwork, including cabling
systems, trochanteric fixation devices,
acetabular reconstruction rings and plates,
cages, mesh and even computer-aided design/
computer-aided manufacturing (CAD CAM)
implants
• Thin, curved osteotomes for removing cement-
less hips. Figure 10.14 An ‘extended’ trochanteric osteotomy
158 Surgery of the hip
Type IIIA – distal fixation can be Long stem cemented implanted with
achieved at the isthmus, despite impaction allograft; long stem
damage to the isthmus and the distally fixed uncemented stem
metaphysis
Type IIIB – damage to the metaphysis Long stem cemented implant with
and isthmus prevent distal fixation morcellized and corticocancellous
from being achieved strut graft; long stem distally fixed
uncemented stem with
corticocancellous strut graft; massive
tumour prosthesis proximal femoral
replacement
Removal of a cemented socket If the above method also fails, the acetabular
If the acetabular component is loose, it will often socket is cut into quarters with a power saw and
come free with minimal effort, typically along can then be removed. It is important that all
with the majority of its cement attached. cement is also removed.
In a well-fixed socket, a curved osteotome is
used to develop a plane between the cup and the Removal of an uncemented socket
cement. Alternatively, a pilot hole can be drilled If the cup is well-fixed, it should be remembered
into the centre of the component and a slap- that it may not need to be removed. In this case,
hammer screwed into it. Once loose, the socket is the liner can be removed but this must be done
removed and the cement is then removed carefully to avoid damage to the liner to socket
piecemeal with small osteotomes. This method locking mechanism. If the locking mechanism is
gives the least bone loss and minimizes the still functioning, a simple liner exchange can be
likelihood of acetabular fracture. performed, remembering that the replacement
160 Surgery of the hip
liner need not be of the same internal diameter or between the bone and the implant with curved
have the same augment or ‘lip’ size’. A con- osteotomes. Care must be taken to avoid excess
troversial measure, in a well-fixed socket with a bone loss.
destroyed or obsolete locking mechanism, is The use of a suitable removal system, such as
cementation of a smaller liner within the shell. Explant (Zimmer, Warsaw, IN, USA), can mini-
If there is significant osteolysis behind the screw mize the bone destruction.
hole in the socket, it is possible to apply
morcellized bone graft through the screw holes to Assessing acetabular bone loss
aid in reducing this. If the socket is to be removed, The most commonly used grading system is the
any screws are removed first. The well-fixed AAOS system. Table 10.2 shows the AAOS
socket is carefully removed by developing a plane system together with possible solutions.
Table 10.2 American Academy of Orthopedic Surgeons (AAOS) classification of acetabular bone loss
at revision hip surgery
Once the guidewire is passed, a jig is placed adults in order to allow return to manual labour.
over it and swept around the entire neck to ensure Continuing indications are:
that there is clearance around the whole diameter, • Failed arthroplasty
i.e. it will not be notched. If the entry point or • Sequelae of infection, particularly tuberculosis
angle is incorrect, the guidewire is removed and • Sickle cell anaemic arthropathy.
replaced.
Once the guidewire is correctly positioned a Contraindications
post drill is used to create a central hole for the
post to be inserted into the femoral head. This is • Contralateral hip disease
then the guide for further cuts. Again, equipment • Ipsilateral knee disease
varies but all have specific cutters and reamers for • Pre-existing lower back pain
shaping of the proximal femur. Care should be • Inflammatory arthropathy – relative.
taken that the size chosen fits with the acetabular
component and that notching is prevented. If a Consent and risks
significant notch is created, the surgeon must
change to a total hip replacement. While cutting • Lower back pain: 60 per cent
and shaping, drapes should be placed over the • Leg length discrepancy: 100 per cent (typically
surrounding soft tissues to prevent bone swarf up to 5 cm)
from entering tissue planes. • Knee pain: 45 per cent
A profile reamer is then used to shape the head • Failure of fusion: 2 per cent clinically but up to
and a step drill to create around six holes in the 30 per cent radiographically
bevelled edge, to act as cement keys. The intended • Malpositioning (it has been shown that the rates
final resting place of the component is marked on of back pain are higher in malpositioned hips)
the femoral head–neck junction. The patient must understand that walking will be
The head is thoroughly washed with pulsed abnormal and running impossible. There is a
normal saline and the appropriate head is significant reduction in walking speed and increase
cemented in situ, typically with low viscosity in energy expenditure.
cement. It is impacted up to the previously
created mark to ensure that it is in place. The hip
is reduced and assessed for stability.
Operative planning
At closure, the gluteus maximus tendon and Planning of the position of fusion is vital. The
quadratus femoris are closed, then closure is as in position is:
THR. Postoperative care and complications are • Flexion of 20–25°
also equivalent to total hip replacement. • Rotation neutral to 10° of external rotation
• Adduction of 0–5°.
HIP ARTHRODESIS A variety of techniques can be used, with intra-
articular or extra-articular fusion achieved.
PREOPERATIVE PLANNING
Anaesthesia and positioning
Below is a description of one common technique
although there are many described in the This is performed as for THR.
literature.
SURGICAL TECHNIQUE
Indications
Approach
Hip arthrodesis is rapidly becoming a procedure
of historical interest only as improvements in The lateral approach is used, as described in the
THR allow implantation in younger patients. It primary arthroplasty section. The patient is
has limited indications now but was used in young positioned supine, rather than in the lateral
164 Surgery of the hip
Procedure
The gluteus medius and minimus complex is left
attached to the greater trochanter and their
anterior and posterior borders defined carefully.
An oscillating saw is used to create an osteotomy,
separating the greater trochanter from the
proximal femur. The abductors remain attached to
the greater trochanter. The greater trochanter and
abductor complex are reflected upwards; this may
require some dissection of the undersurface of the
abductors away from the superior capsule.
The acetabulum is dissected of soft tissues,
carefully defining from the sciatic notch at the Figure 10.16 A hip arthrodesis with cobra plate
back, around the superior border and round to the
anterior border. A blunt Hohmann retractor is recommends the use of an image intensifier at this
inserted into the sciatic notch (this protects the stage to further confirm positioning.
sciatic nerve and the superior gluteal vessels) and The flexion position of 20–25° is confirmed by
another is hooked around the iliopectineal performing the Thomas test. The greater
eminence anteriorly. A horizontal osteotomy is trochanter is then repositioned at the anatomical
carefully created between the two retractors, site. This can now be attached back onto the
running just above the superior surface of the femur with a screw through the greater trochanter
acetabulum. This can be begun with an oscillating and the cobra plate (Fig. 10.16). The remaining
saw but should be completed with an osteotome screw holes are drilled and further cortical screws
to reduce the danger of sciatic nerve injury. inserted to strengthen the arthrodesis.
A corresponding horizontal surface is created
on the top of the femoral head by removing a
small portion of the head with an oscillating saw.
Closure
Curettes are used to remove any areas of Closure is similar to the lateral approach for total
persistent cartilage on the femoral head and the hip replacement: a layered closure followed by the
acetabulum. A retractor is inserted into the pelvic surgeon’s choice of skin closure.
osteotomy and used to lever the osteotomy and
displace the distal portion approximately 1 cm POSTOPERATIVE CARE AND
medially with respect to the proximal ilium. By INSTRUCTIONS
removing the sandbag from under the buttock,
the position for arthrodesis can be accurately Thromboembolism should be prevented by early
assessed. mobilization and the addition of chemical or
The cobra plate is attached over the osteotomy mechanical measures in patients at increased risk.
site; this only requires one screw into the pelvis Two further doses of the antibiotic given at
and one into the femur at this stage. Careful induction should be given at 8 hours and 16 hours
palpation of the pelvis, patella and malleoli is after surgery.
carried out to confirm the correct position of the Early mobilization is non-weightbearing, with
leg before the arthrodesis. The author the aid of crutches. Radiographic signs of union
Femoroacetabular impingement surgery 165
PREOPERATIVE PLANNING
Indications
• It is a last resort operation and used as a salvage FEMOROACETABULAR IMPINGEMENT
procedure, generally in patients with resistant SURGERY
infections or comorbidities which necessitate a
quick operation.
• Sepsis of either THR or the native hip
PREOPERATIVE PLANNING
• Aseptic loosening of THR
• Painful hip conditions in a patient otherwise
Indications
immobile, particularly in degenerative neuro- • Pain and/or restricted range of motion
muscular conditions. associated with a recognized anatomical
deformity.
Consent and risks
This can be of two types: cam or pincer; these can
• Nerve injury also coexist (Fig. 10.17). The cam deformity of the
• Limb length discrepancy: it is usually 3–12 cm, femur is also referred to as a ‘pistol grip’
depending on resection deformity. The most typical presentation is groin
• Recurrence of infection (if a septic indication): pain worse on prolonged flexion e.g. sitting. The
10 per cent impingement test of the hip is usually positive.
• Nearly all will be reliant on walking aids after (The hip is held in 90° flexion and passively
surgery; many have poor function but most have internally rotated and adducted.)
good pain relief
Contraindications
Normal CAM
Pincer Mixed
PROCEDURE
Structure at risk
The osteoplasty of the head–neck junction is
• Lateral femoral cutaneous nerve carried out with a small (10–15 mm) osteotome.
An assistant internally and externally rotates the
Dissection is continued through fat and superficial hip to allow complete excision of the bump.
fascia. The lateral femoral cutaneous nerve is The resection is directed distally to produce a
identified, running over the fascia between the bevelled resection, restoring the offset between
tensor fascia lata and sartorius. The nerve is the femoral head and neck. This creates a ‘V’-
retracted medially and the fascia incised shaped valley over the anterior head–neck
between the two muscle bellies. This provides an junction. The depth of the valley can be assessed
interval with the muscle belly of the tensor by bringing the hip back into the position of the
fascia lata laterally and that of the sartorius impingement test. The aim is a gain in both
medially. internal rotation and flexion of the hip by over
The dissection is continued down between the 10°. If the valley is not deep enough, it can be
tensor fascia lata and sartorius, until the direct and further deepened in a similar manner. The aim is
reflected heads of the rectus femoris are complete excision of the protuberant bump, until
identified. the remaining femoral head is spherical and no
168 Surgery of the hip
Closure
Non-absorbable suture is used to close the skin
Figure 10.18 Entry to the hip joint defects.
170 Surgery of the hip
• Impingement syndrome
• Assessment of loose total hip implants,
including aspiration in suspected sepsis.
Contraindications
• Contrast allergy
• Uncontrolled bleeding dyscrasias.
Operative planning
Preoperative anteroposterior and lateral views of
the pelvis and hip should be available. A
fluoroscope and contrast need to be available.
• Anteroposterior in internal and external while removing the image of the implant and
rotation in flexion and extension cement.
• Shoot-through lateral.
POSTOPERATIVE CARE AND
If impingement is suspected, an image in flexion INSTRUCTIONS
and internal rotation is taken.
If the arthrogram is taken for planning an The patient may fully weightbear immediately.
osteotomy, live screening can be used to locate a Risks are very low, with infection and contrast
position of best fit of the femoral head in the reaction both significantly <1 per cent.
acetabulum. This is particularly useful in cases of
Perthes disease. RECOMMENDED REFERENCE
If imaging a total hip implant, digital
subtraction can be used by taking a plain view O’Neill DA, Harris WH. Failed total hip
prior to injection of contrast and overlaying it on replacement: assessment by plain radiographs,
the contrast anteroposterior view. This will show arthrograms, and aspiration of the hip joint. J Bone
areas of contrast intrusion around the implant Joint Surg Am 1984;66:540–6.
Viva questions
1. How does revision surgery differ when 10. What factors influence your choice of hip
infection is suspected? implant for total hip replacement?
2. What are the indications, benefits and 11. What are the contraindications to total hip
drawbacks for hip arthrodesis? replacement?
3. What are the surgical options for a 50-year-old 12. What factors affect the quality of the cement
man with symptomatic osteoarthritis of the mantle in cemented hip replacement?
hips?
13. Which nerves can be injured in hip surgery?
4. Describe the anatomy of the sciatic nerve
14. What factors contribute to dislocation in total
around the hip.
hip replacement?
5. How do you classify bone loss around a
15. Describe the portals used in hip arthroscopy.
femoral/acetabular component of a hip
replacement? 16. How do you perform a hip arthrogram?
6. What complications do you warn the patient 17. What are the potential advantages of hip
about prior to hip replacement? What are their resurfacing over total hip replacement?
incidences?
18. What imaging would you consider before
7. What are the indications for Girdlestone’s revising a total hip replacement?
procedure?
19. What are the options for reconstruction of
8. When would allograft be used in hip cavitary bone loss in acetabular revision
replacement? What types of allograft are used surgery?
and why?
20. How can femoroacetabular impingement be
9. Which approach do you use for total hip treated surgically?
replacement and why?
11
Surgery of the knee
Lee David and Timothy W R Briggs
OPERATIVE PLANNING
Clinical examination should pay careful attention
to alignment, deformity, instability, range of
movement and extensor mechanism function.
Scars should be carefully noted and a distal
neurovascular assessment must be performed.
Recent weightbearing anteroposterior, lateral Figure 11.1 The mechanical
and skyline patella radiographs must be available and tibiofemoral axes of the
and long-leg alignment views may be helpful to lower limb
174 Surgery of the knee
medial border of the patella tendon distally (Fig. • The common peroneal nerve is in danger from
11.2). There should be at least a 3 mm cuff of injudicious lateral retractor positioning
quadriceps tendon left attached to vastus medialis • Popliteus tendon can be divided during posterior
and a cuff of medial retinaculum attached to the femoral condylar or tibial bone cuts
patella to allow adequate closure. • The popliteal vessels and tibial nerve can be at
The medial capsule is released subperiosteally risk during posterior osteophyte removal,
off the proximal tibia to gain exposure to the posterior capsular release, PCL resection and
medial compartment. In a varus knee, this dis- when cutting the posterior tibial cortex with the
section should include the deep medial collateral saw, if not protected. The anatomy of the
ligament and extend to the posteromedial corner. popliteal artery in relation to the knee joint is
In a valgus knee this medial release should be extremely variable
minimized to the anteromedial corner in order to
gain adequate exposure.
With the knee in extension, the patella is In the vast majority of cases, the bony cuts can
everted and the knee flexed. The retropatellar fat be made in the conventional manner with the use
pad may be partially or fully excised if necessary. of standard instrumentation. Whether the femoral
The visible remnants of the medial and lateral or tibial cut is made first depends on the surgeon’s
menisci may be resected at this stage and the preference and type of prosthesis used.
anterior cruciate ligament (ACL) must be divided Femoral cuts
and resected. If a posterior cruciate substituting
implant is to be used the posterior cruciate The femur should be prepared with the use of an
ligament (PCL) can be resected now by dissecting intramedullary alignment jig if at all possible. The
it from its femoral attachment with diathermy. tibial cut can be made by using intra- or
Osteophytes may be debrided at this stage. extramedullary alignment jigs, depending on the
surgeon’s preferred method and the degree of
PROCEDURE extra-articular deformity of the tibia. There is
evidence to show that intramedullary referencing
The primary goals of surgery are pain relief, of the tibial cuts is more accurate but it has also
restoration of function and longevity of the been shown to increase the risk of fat embolism.
prosthesis. The immediate technical aims of the Femoral preparation is undertaken with the
operation are: anatomical alignment, good range of knee flexed and the patella everted. A large drill-
motion, good stability and ligamentous balancing bit is used to create entry point in the distal
throughout the range and good patella tracking. femoral canal at a point approximately 1 cm
Achievement of all these goals can only be accom- anterior to the insertion of the PCL within the
plished by accurate bone cuts, equal flexion/ trochlear notch. The entry point can be slightly
extension gaps, correct soft tissue balancing, widened with a rotational movement of the drill.
adequate fixation of implants and by addressing The intramedullary rod should be inserted into
any patellofemoral problems, while minimizing the the canal with care, especially if a previous total
risk of any adverse intraoperative events. The hip replacement has been performed. The distal
surgeon must appreciate that a total knee replace- femoral cutting jig is positioned over the rod and
ment is as much a soft tissue operation as a bony adjusted so that the distal cut is set at a 5–9°
procedure. valgus angle to the appropriate side of the knee to
be replaced (Fig. 11.3). Ideally, this should be
Bone cuts
chosen to match the anatomical axis of the
contralateral limb, if normal.
Structures at risk The distal cutting jig is secured with two or
three pins which should be fully inserted to
• The MCL must be carefully protected during bone
ensure that the saw is not hampered and to allow
cuts
the saw blade to make ample excursion to
• Patella tendon
complete the cut. The amount of distal femoral
176 Surgery of the knee
minor notching occurring, this should be from the more abnormal medial compartment. In
controlled and any sharp edge of anterior cortex a valgus knee the amount of tibial resection can be
should be smoothed off with the saw or a bone more difficult to estimate, but should generally
file. The cut bone fragments can then be removed extend to the level of the tip of the fibula head on
with knife and forceps and the posterior condylar the lateral side. When at the correct height, as
cuts can be removed with a broad osteotome. The confirmed with a stylus passed through the slot on
distal femur is then examined to ensure that the the tibial cutting block and onto the tibial plateau,
cuts are complete. Large posterior osteophytes the cutting block can then be fixed with pins,
apparent on the preoperative lateral radiograph or advanced closer to the tibial surface, locked in
evident after bone cuts can be removed by lifting place and the intramedullary rod removed.
up the femur and carefully using a broad The angle of the tibial cut can then be checked
osteotome or saw under direct vision. with an extramedullary alignment rod. If
extramedullary referencing alone is used, the rod
Tibial cut should be in line with the anterior tibial spine and
the distal tip of the rod should lie just medial to
The tibial cut should be made perpendicular to
the centre of the ankle joint (as this is where the
the axis of the tibia in the coronal plane with an
mechanical axis of the limb passes). Using
anteroposterior slope of approximately 3° in the
anatomical landmarks in the foot, such as the
sagittal plane (Fig. 11.5). If intramedullary
second metatarsal, is less reliable as rotation can
referencing is used, the entry point should be
occur within the hindfoot and midfoot. With
made with a drill at the centre point of the tibia.
extramedullary referencing, the anteroposterior
The intramedullary rod should be inserted
slope of the tibial cut can be introduced either by
comfortably into the tibial canal and the cutting
use of an angled cutting block or by adjustment of
block adjusted in a varus knee to allow resection
the extramedullary jig itself. If the femoral cuts
of approximately 10 mm from the more normal
have already been made, the tibia can be
lateral compartment and approximately 2 mm
externally rotated and subluxed anteriorly to
allow exposure of the entire articular surface of
the tibia. If the PCL must be preserved, a small
portion of bone adjacent to the PCL attachment
can be protected with a broad retractor and
Cut preserved during the tibial cut.
After the tibial resection is complete, the
remaining meniscal remnants can be excised and
the tibial component is sized and, following a trial
of the components, the tibia can be prepared to
accept the stem or keel of the prosthesis. The
Perpendicular
tibial component should lie in slight internal
rotation on the tibia, with the midpoint of the
tibial baseplate being in line with the medial third
of the patella tendon to optimize patellofemoral
tracking.
Flexion/extension gaps
The femoral and tibial cuts should be made such
that the rectangular spaces created are the same in
both full extension and 90° of flexion (Fig. 11.6).
Long axis of tibia The fact that the mediolateral tibial slope in the
coronal plane is 3° to the perpendicular means
Figure 11.5 The tibial cut that the posterior femoral bone cut in flexion
178 Surgery of the knee
Varus deformity
Figure 11.7 The effect of external rotation of the This is by far the most common deformity in the
femoral cutting block osteoarthritic knee. Bone loss is usually from the
Primary total knee replacement 179
medial tibial plateau. An important part of the insert is needed to achieve stability, the PCL may
medial release involves excision of the medial need to be recessed or resected to allow full
osteophytes from the distal femur and proximal extension. Occasionally, the lateral collateral
tibia with either an osteotome or bone nibbler. As ligament needs to be released off the femur and if
described above, the preliminary soft tissue there is severe fixed deformity with associated
release is performed during the initial exposure fixed flexion, the posterolateral capsule and lateral
and involves the medial capsule and deep MCL, head of the gastrocnemius must be released off
released subperiosteally off the proximal medial the femur.
tibia from anterior to posterior using either a
periosteal elevator or diathermy. The next stage Fixed flexion deformity
should be extension of the medial release distally Fixed flexion deformity is caused by contracture
to release the superficial MCL and pes anserinus. of the posterior structures of the knee and
If further releasing is required, one should posterior distal femoral osteophytes. If fixed
consider releasing the PCL as this can often be a flexion is present the amount of distal femoral
deforming force. resection needs to be increased by approximately
1 mm for every 2–3° of fixed flexion present to
Valgus deformity increase the extension gap. This is limited by the
fact that increasing distal femoral resection
Structure at risk elevates the joint line. If there is severe fixed
flexion deformity, it is usually necessary to resect
The common peroneal nerve is at risk following the PCL. The posterior capsule can be released
correction of a fixed valgus and fixed flexion subperiosteally with a curved osteotome follow-
deformity. ing bone cuts. Posterior condylar osteophytes can
be excised with an osteotome and removed
This is the most common deformity in carefully with Kocher forceps (Table 11.1).
rheumatoid arthritis and can occur in
osteoarthritis. Bone loss is usually from the lateral Table 11.1 The stages of soft tissue releases in
femoral condyle. A lateral parapatellar approach is deformity correction
rarely required. It is commonly necessary to use a
PCL sacrificing implant or, if the MCL is non- Varus Osteophytes, deep medial collateral
functional it may even be necessary to use a deformity ligament, superficial medial collateral
constrained prosthesis. There should be minimal ligament, pes anserinus, posterior
medial releasing only to allow exposure, due to cruciate ligament, posteromedial
capsule, semimembranosus
attenuation of the medial stabilizing structures.
Osteophytes should be removed from the distal Valgus Osteophytes, lateral capsule, iliotibial
femur and proximal tibia. The distal femoral cut deformity band, popliteus, lateral collateral
can be set at 5° to ‘overcorrect’ the deformity. The ligament, posterior cruciate ligament,
intermuscular septum, biceps tendon,
lateral patellofemoral ligament may need to be
lateral head of gastrocnemius
released to allow eversion of the patella. The
lateral border of the tibia should be demarcated Fixed flexion Distal femoral resection, posterior
with a knife or diathermy to release the lateral deformity osteophytes, posterior capsule, posterior
capsule. If the knee is tight laterally in extension, cruciate ligament
which is common, the iliotibial band should be
released off Gerdy’s tubercle. If the knee is tight
laterally in flexion, which is less common, the Patella
popliteus tendon should be released. The PCL can
be a deforming force and at this stage if alignment Whether the patella should be resurfaced is still a
cannot be corrected the PCL should be released. controversial issue. Some surgeons always
If there is attenuation of the MCL and a thick resurface, some never resurface and some do if
180 Surgery of the knee
there are patellofemoral symptoms or if the Where total knee arthroplasty is performed
retropatellar surface is severely affected. following a previous patellectomy, a PCL
The vast majority of patella buttons used are substituting implant should be used in order to
polyethylene. There are two types of patella avoid excessive anterior subluxation of the femur
button – onlay and inlay. As the respective names on the tibia due to an already relatively attenuated
suggest, these designs utilize a prosthesis that is extensor mechanism.
implanted either onto or into the resected
retropatella surface. To resurface the patella, the Implantation of prosthesis
knee should be extended and the patella fully
everted. Peripheral osteophytes can be removed Condylar knee replacement systems can be
with a bone nibbler to demarcate the actual cemented, uncemented or a hybrid design that
articular surface. The thickness of the patella usually has a cemented tibial component and an
should be measured and the amount of uncemented femur. Uncemented implants now
bone/cartilage removed should approximately often have a hydroxyapatite coating. The
correspond to the thickness of the implant, polyethylene insert can either be modular or
although if there is severe damage it may be less. monoblock (all polyethylene or metal backed),
Resecting too little bone runs the risk of and can be of fixed or mobile bearing design.
overstuffing the knee and if a sclerotic surface is In cemented knee arthroplasty, two mixes of
left behind, fixation is compromised, whereas antibiotic-impregnated polymethylmethacrylate
resecting too much increases the risk of fracture. (PMMA) bone cement should be used. The
Many implants now have calibrated clamps and surgeon should be familiar with the
jigs that help indicate the correct resection level. biomechanical properties of the cement and its
To avoid an increase in the ‘Q’-angle and mixing technique. Following satisfactory trials, the
therefore reduce the likelihood of maltracking, selected components are checked by the surgeon
the patella button should be slightly medialized and opened. The knee is flexed and the patella
and both the femoral and tibial components everted allowing the tibia to be subluxed
should be lateralized and slightly externally anteriorly, with a Hohmann retractor or similar,
rotated. When trialing the implants and checking and the prepared surface of the tibia exposed
the patellofemoral tracking the ‘rule of no medially and lateral with spiked retractors. The
thumbs’ should be employed, i.e. the knee should knee is washed out thoroughly with normal saline
be put through a range of movement and the pulsed lavage in order to expose the bone
patella should not sublux laterally even before the trabeculae and maximize the mechanical fixation
medial parapatellar reticulum is closed and of the cement. If sclerotic bone surfaces are
without the use of a guiding thumb to ‘aid’ present, a small drill can be used to make multiple
tracking. If the patella maltracks laterally, a lateral small ‘key holes’. When intramedullary
parapatellar retinacular release is usually required. referencing has been used, many surgeons insert a
This should be performed with a diathermy (as it bone block into the medullary canal to reduce
may lead to significant bleeding and bruising blood loss. The knee should be thoroughly dried
postoperatively), and should be carried out from with suction and swabs. The cement can then be
distal to proximal and from deep to superficial. mixed and the whole surgical team should change
There are often palpable fibrous bands and release the outer layer of gloves. In most situations,
of these is sometimes enough. To enable the cementing of both components can be performed
release to be performed, the patella is lifted simultaneously, but on occasions it may be
anterolaterally with the knee in extension. If desirable to perform cementing of the
possible, the superior lateral geniculate artery components separately with different mixes of
should be preserved to avoid devascularization of cement.
the patella. Superficial releasing with a resultant To ensure a satisfactory and efficient
subcutaneous flap and undermining of the lateral cementation process, everything should be
skin should be avoided. prepared and ordered in a logical fashion. The
Primary total knee replacement 181
tibial component is usually implanted first. reduces the chance of stitching the drain in when
Cement can be applied onto the tibial surface closing the medial parapatellar retinaculum.
either via a gun with short nozzle or with a The actual closure technique varies with
spatula. The tibial component is positioned in the surgical preference but it is important that the
correct orientation and firmly seated with a soft repair is watertight and that range of motion is
impactor and hammer. Excess cement is removed. maintained with no patella maltracking. Closure
A trial insert is then applied to the tibial baseplate of the knee in flexion ensures that the correct
and the femur lifted up. Cement can be applied to tension is achieved. The deep layer is closed with
both the exposed distal femur and implant, but as a heavy suture (e.g. no. 1 Vicryl), by means of a
it is difficult to remove cement from the posterior continuous repair of the quadriceps tendon,
aspect of the knee following implantation, in this interrupted repair of the parapatellar retinaculum
region it is preferable to place the cement onto and continuous repair of the medial capsule to
the prosthesis rather than onto bone. The femoral patella tendon. The deep fascia can be closed as a
component must be positioned carefully in separate layer if desired or the subcutaneous fat
relation to the distal femur; in particular flexion of can be opposed with deep interrupted sutures.
the femoral component should be avoided. The The deep dermal layer is closed with a continuous
femoral component must be firmly impacted absorbable suture to allow tension-free closure of
and any excess cement should be removed. the skin with surgical staples or a continuous
The knee is then fully extended and axial absorbable subcuticular suture. A sterile occlusive
compression applied (note: hyperextension leads dressing and a padded compression bandage is
to uneven cement pressurization and may cause applied and the drain secured with adhesive tape.
posterior ‘lift-off’ of the tibial baseplate). If the
patella is resurfaced the orientation should be POSTOPERATIVE CARE AND
checked and once positioned, the patella is INSTRUCTIONS
compressed and held with a clamp. The knee can
Regular neurovascular, cardiovascular and
then be flexed again and any further cement
respiratory observations are mandatory. Urine
extruded can be removed quickly. The knee is
output, temperature and drainage should also be
then extended and further axial compression
monitored. Adequate analgesia should be
applied. The trial insert is removed and the
administered. Mechanical and, if indicated,
baseplate inspected to ensure that there is no
chemical thromboprophylactic measures are
cement or soft tissue present which may impede
taken. Two further doses of prophylactic
the insert. The definitive insert can then be
antibiotics are administered at 8 hours and 16
positioned correctly and impacted fully using the
hours after surgery. The use of a reinfusion drain
appropriate instrumentation.
allows for autologous blood transfusion.
In uncemented knee arthroplasty, there must be
Haemoglobin levels should be checked 24–48
good bone stock and accurate bone cuts in order
hours after the procedure. Any drains, urinary
to allow good primary press fit and secondary
catheters, epidural lines and intravenous cannulae
osseointegration of the implant.
should be removed as soon as appropriate to avoid
unnecessary portals of infection. Pressure
Closure dressings should be reduced and ice applied. Full
weightbearing and active range of motion
Once the cement has set, the knee can be washed exercises should be commenced as soon as
out again with pulsed lavage. Some surgeons possible. The wound should be inspected and
prefer to deflate the tourniquet and gain check radiographs performed prior to discharge.
haemostasis prior to closure. However, most The patient must be declared safe for discharge
surgeons favour closure of the knee over a and for routine cases should be able to straight leg
reinfusion drain and application of a pressure raise and flex the knee from 0° to 90°.
bandage prior to deflating the tourniquet. If a Skin clips should be removed 10–14 days after
drain is used, placing the drain in the lateral gutter surgery and an outpatient appointment should be
182 Surgery of the knee
extensor mechanism function. Infection must be other extensile approaches may be required to
excluded. Scars should be carefully noted and a gain adequate exposure.
distal neurovascular assessment must be
performed. If the skin over the knee is of poor Landmarks and incision
quality it may be necessary to consult a plastic
surgeon. All scars should be marked with a sterile pen. If
Recent weightbearing anteroposterior, lateral possible, a generous midline incision is used. If
and skyline patella radiographs must be available there are multiple longitudinal incisions in front
and long-leg alignment views are helpful in of the knee the most lateral scar should be used to
guiding alignment. Computed tomography may avoid necrosis of the intervening strip of skin due
occasionally help. It is absolutely essential that a to the fact that the blood supply passes from
cause for the failure is found. Templating of medial to lateral. The incision needs to be long
preoperative radiographs should be performed if enough to allow adequate exposure and avoid
possible and it is the responsibility of the surgeon excessive skin stretching. It may be desirable to
to ensure that the required implants are available. excise the old scar.
The choice of implant is extremely important
and is essentially governed by the degree of bone
Superficial dissection
loss and ligamentous instability present. In most
cases, due to osteolysis in the metaphyseal region Skin flaps should be kept as thick as possible and
and suboptimal surfaces for fixation, stemmed should not be undermined. The quadriceps and
implants are used, which can either be cemented patella tendons should be defined. It may be
or uncemented and press-fit with flutes for necessary to extend the incision until ‘virgin’
rotational stability. Small, contained defects can tissue is found, in order to find the correct tissue
be filled with cement or bone graft but plane.
uncontained defects need to be restored with
augments or wedges. Massive bone loss may
require a distal femoral or proximal tibial
Deep dissection
endoprosthetic replacement. The use of a PCL
substituting design is usually recommended. If Structures at risk
there is some degree of ligamentous laxity a semi-
constrained implant with a high post should be • The medial collateral ligament is at risk from
used to give valgus/varus stability but in the case aggressive synovectomy and medial release
of MCL deficiency a rotating hinged prosthesis • The patella tendon is usually thickened, tight and
should be used. Infected total knee replacements at risk of avulsion. The patella tendon and
should ideally be revised as a two-stage procedure. quadriceps tendon should be thinned down by
excision of any thickened fibrous tissue and the
Anaesthesia and positioning articulating surface of the patella should be
exposed. If the patella does not evert or sublux
See ‘Primary total knee replacement’ (p. 173). The easily, one or more of the measures below needs
operation is likely to last longer than a primary to be performed
knee replacement, leading to more physiological • All other important structures around the knee
disturbance. It can be helpful to exsanguinate the are at greater risk of injury during revision
leg after preparation and draping to save surgery than in the primary procedure due to
tourniquet time. scar tissue, difficulty in exposure and stiffness or
laxity
SURGICAL TECHNIQUE
Although many revision procedures can be The standard medial parapatellar approach is
performed via the medial parapatellar approach, usually performed initially but an alternative is
as described in primary total knee arthroplasty, the Insall approach, which extends longitudinally
184 Surgery of the knee
over the patella at the junction of the medial one- border of the patella tendon and lateral
third and lateral two-thirds. The medial parapatellar retinaculum. To reduce subsequent
retinaculum is dissected subperiosteally off the blood loss, it can be performed using diathermy.
patella to allow a cuff for repair. It is usually Full thickness lateral release should be avoided if
necessary to perform an extensive synovectomy in possible, but if this is necessary to gain exposure
order to improve exposure and to recreate the the superior lateral geniculate artery should be left
suprapatellar pouch and medial and lateral intact and the lateral parapatellar retinaculum
gutters. The fat pad is excised. Medial release should be closed later.
should be performed to allow exposure to the
tibia. There is usually a plane visible between the Quadriceps snip
pseudocapsule and normal tissue and this can be This involves a lateral incision into the quadriceps
developed with knife or diathermy and the tendon from the proximal extent of the standard
pseudocapsule carefully pulled away under medial parapatellar approach (Fig.11.8a). A
tension. As the PCL is usually sacrificed, this can quadriceps snip can be performed in combination
be performed following implant removal. with a more distal lateral release, provided that
the superior lateral geniculate artery is preserved.
Lateral parapatellar release
It is almost always necessary to perform a lateral Quadriceps turndown
parapatellar release to allow eversion of the This consists of an incision passing distally and
patella. It is usually beneficial to perform the laterally from the proximal extent of the standard
lateral parapatellar release early on. The release medial parapatellar approach (Fig. 11.8b). The
should be performed from deep to superficial and superior lateral geniculate artery should be
from distal to proximal, alongside the lateral preserved. The inverted V thus formed can be
closed as a Y, thereby advancing the quadriceps depends on the amount of bone loss and
tendon and patella distally. ligamentous instability present.
Reconstruction
Following successful removal of implants and
cement, any fibrous membrane on the distal
femur and proximal tibia is carefully removed
with a small, sharp curette and bone nibblers.
Ideally, the remaining bone surfaces should consist
of trabecular bone to allow optimum cementa-
tion. Any small, contained, cavitatory defects can
be filled with morsellized bone graft or cement
but larger, uncontained, segmental defects need to
be reconstructed with augments or wedges (Fig.
6cm long 11.10). Where there is massive bone loss
extending into the metaphyseal region a modular
Figure 11.9 Tibial tubercle osteotomy (leaving the endoprosthetic implant may need to be used with
lateral soft tissues undisturbed) distal femoral or proximal tibial replacement and
186 Surgery of the knee
PREOPERATIVE PLANNING
Anaesthesia and positioning
Indications
Anaesthesia, positioning, preparation and draping
Patellofemoral replacement is indicated in the are similar to that for primary total knee
treatment of pain from isolated patellofemoral replacement.
188 Surgery of the knee
Femur
UNICOMPARTMENTAL KNEE
To expose the distal femur, two Hohmann
retractors are placed medially and laterally.
REPLACEMENT
The anterior surface of the distal femur is
exposed by excising the overlying synovium PREOPERATIVE PLANNING
with coagulating diathermy. The femoral
component should sit flush with the anterior Indications
distal femur without notching, with the correct
degree of rotation to ensure restoration of the Unicompartmental knee replacement is indicated
lateral ridge and good tracking. The implant in the treatment of painful osteoarthritis when
should not be situated too far distal within the non-operative management has failed. The
notch, as this can cause impingement and catching following criteria must be met:
of the patella in full flexion. The femoral bone • Osteoarthritis mainly confined to one
cuts can be based on either intramedullary or compartment
extramedullary referencing. Individual implants • Varus or valgus deformity must be correctable
rely on different anatomical landmarks for to normal
rotational alignment, e.g. long axis of tibia, • Fixed flexion deformity less than 10°
transepicondylar axis of distal femur, and specific • Minimum flexion of 105°
instruction manuals should be referred to. Most • Intact knee ligaments.
bone cuts are made using sizing jigs and cutting
guides. Contraindications
Trials are then performed and tracking assessed.
Final adjustments and preparations can then be • General contraindications to knee arthroplasty
made including lateral parapatellar release if (see ‘Primary total knee replacement’, p. 172)
necessary. Components are cemented in place. • Inflammatory arthritis
• Failure to meet criteria above
• Patellofemoral osteoarthritis – relative. This is a
Closure controversial and debatable issue, with some
If a lateral parapatellar release has been performed evidence showing no detrimental effect of the
a drain should be inserted. The knee should be presence of patellofemoral osteoarthritis on
closed in flexion in a similar manner to a primary results.
total knee replacement.
Consent and risks
POSTOPERATIVE CARE AND • Most risks and complications of primary total
INSTRUCTIONS knee replacement can occur in
unicompartmental knee replacement
As for primary total knee replacement. • The rate of conversion to total knee replacement
is around 3 per cent at 3 years
• Medial knee pain is common and usually resolves
RECOMMENDED REFERENCES with time. Persistent anteromedial knee pain
may be associated with a degree of MCL damage
Ackroyd CE, Newman JH, Evans R, et al. The intraoperatively
Avon patellofemoral arthroplasty: five-year • Dislocation of the insert can occur with mobile
survivorship and functional results. J Bone Joint bearings, especially if ACL laxity is present
Surg Br 2007;89:310–15. • Progression of arthritis may require revision to
Cartier P, Sanouiller JL, Khefacha A. Long-term total knee replacement. Although this can be
results with the first patellofemoral prosthesis. relatively straightforward, there is often
Clin Orthop Relat Res 2005;(436):47–54.
190 Surgery of the knee
significant bone loss, especially around the tibial of the patella tendon and proximally up to the
baseplate and it may be necessary to use a stem medial parapatellar retinaculum. The medial
and wedge capsule is dissected subperiosteally off the
proximal tibia to gain exposure to the medial
compartment. The dissection should not extend
OPERATIVE PLANNING beyond the anteromedial corner and should not
involve any release of the MCL. The medial
Recent weightbearing anteroposterior, lateral and portion of the fat pad can be excised. The anterior
skyline patella radiographs must be available and two-thirds of the medial meniscus can be excised
stress views may be helpful. It is essential that the at this point, with the posterior horn removed
site of pain should correlate with radiographic later following bone cuts. This should give
findings. It is sometimes necessary to perform adequate exposure of the medial compartment
magnetic resonance imaging or arthroscopy to and it should be possible to inspect the ACL,
assess the integrity of the ACL and the rest of the patellofemoral joint and lateral compartment.
knee, although in most cases the decision can be This operation can usually be performed
made by the history, examination and plain through a relatively minimally invasive approach,
radiographs. However, the final decision is made at with the skin incision being used as a ‘mobile
the time of operation. window’ to gain access to the femur or tibia with
varying degrees of knee flexion. However, if
Anaesthesia and positioning exposure is difficult, the skin incision and deep
dissection should be extended to allow the patella
This is essentially similar to that described for
to be subluxed laterally, although it should not
total knee replacement. However, as
usually be necessary to involve the quadriceps
unicompartmental knee replacement is usually
tendon or vastus medialis.
performed via a less invasive approach, the use of
regional anaesthesia can be avoided, if desired, by
Procedure
the administration of local anaesthetic into the
wound and deep tissues. Some surgeons prefer to
use a leg holder with the knee flexed, the hip Structures at risk
abducted and the leg over the side of the
• The MCL must be protected throughout
operating table or the foot of the table removed.
• The ACL is at risk during the sagittal tibial cut
This allows the knee to be stressed and can
with the reciprocating saw and should be
improve exposure.
retracted
• The patella tendon can be damaged during
SURGICAL TECHNIQUE reaming of the femoral condyle
saw, perpendicular to the long axis of the tibia. cemented and medial unicompartmental knee
The wedge of tibia can then be removed with a replacements are usually mobile bearing.
Kocher forcep.
The femoral preparation uses femoral Closure
intramedullary alignment and the tibial cut as a
combined reference (Fig. 11.11). The flexion gap Closure is done in layers, with continuous
is set by making the posterior condylar cut first. absorbable sutures and a continuous subcuticular
The initial reaming of the distal femur is then suture or staples to the skin. It is not usually
carried out in order to position the trials in place necessary to use a drain.
and the flexion and extension gaps are equalized
by taking more bone off the distal femur.
Final trials and preparations can then be made
Lateral unicompartmental knee
and the definitive implants inserted. If there is replacement
impingement of the bearing anteriorly on the
This is much less commonly performed than
femoral condyle in full extension, the condyle can
medial unicompartmental knee replacement. It
be fashioned to allow clearance. The majority of
can either be performed via a midline approach
unicompartmental knee replacements are
with the patella everted, or a direct lateral
parapatellar approach. The procedure itself is
analogous to that of medial unicompartmental
surgery. Due to the increased excursion of the
lateral compartment during knee movement, the
Centre of use of a fixed bearing is required.
femoral head
RECOMMENDED REFERENCES
Parallel to Koskinen E, Eskelinen A, Paavolainen P, et al.
IM canal Comparison of survival and cost-effectiveness
between unicondylar arthroplasty and total knee
arthroplasty in patients with primary
osteoarthritis: a follow-up study of 50,493 knee
replacements from the Finnish Arthroplasty
Register. Acta Orthop 2008;79:499–507.
Murray DW, Goodfellow JW, O’Connor JJ. The
Oxford medial unicompartmental arthroplasty: a
ten-year survival study. J Bone Joint Surg Br
1998;80:983–9.
Figure 11.11 Component Steele RG, Hutabarat S, Evans RL, et al.
alignment in Survivorship of the St Georg Sled medial
unicompartmental knee unicompartmental knee replacement beyond ten
replacement years. J Bone Joint Surg Br 2006;88:1164–8.
192 Surgery of the knee
Shift of
Lateral opening mechanical axis
wedge to medial
osteotomy Opening wedge compartment
Mechanical
axis passes
through lateral
compartment
Dissection
The ECG sticker placed over the femoral head is
The incision is deepened along the same line until palpated through the drapes and an alignment rod
the fascia lata is exposed. The fascia lata is split can be placed to lie between this point and the
and the vastus lateralis can either be divided or centre of the articular surface of the ankle joint.
incised and lifted off the femur at its posterior When the osteotomy is opened by the correct
border. Any blood vessels encountered should be amount, the mechanical axis is shifted to the
coagulated and subperiosteal dissection is desired point, i.e. the centre of the medial tibial
194 Surgery of the knee
plateau. This improves the efficiency of the use of POSTOPERATIVE CARE AND
fluoroscopy, minimizes X-ray exposure and helps INSTRUCTIONS
to minimize operation time.
A first guide wire is inserted with the power As for proximal tibial osteotomy.
driver from the lateral cortex in a medial and
slightly caudal direction. The wire should emerge RECOMMENDED REFERENCES
in the metaphyseal region of the distal femur at
Backstein D, Morag G, Hanna S, et al. Long-term
the junction of the medial femoral condyle and
follow-up of distal femoral varus osteotomy of the
the supracondylar ridge. A second wire is then
knee. J Arthroplasty 2007;22(Suppl 1):2–6.
introduced to lie exactly superimposed on the first
Brouwer RW, Raaij van TM, Bierma-Zeinstra SM,
on a true anteroposterior fluoroscopic image,
et al. Osteotomy for treating knee osteoarthritis.
indicating that the wires are exactly parallel to the
Cochrane Database Syst Rev 2007;18:CD004019.
joint surface. This second wire can be introduced
Puddu G, Cipolla M, Cerullo G, et al.
through a parallel guide.
Osteotomies: the surgical treatment of the valgus
The osteotomy can then be performed with an
knee. Sports Med Arthrosc 2007;15:15–22.
oscillating saw, using either the guide wires or
cutting jig to help control the saw. The saw is
placed on the proximal side of the wires and
advanced approximately two-thirds of the
PROXIMAL TIBIAL OSTEOTOMY
distance across the femur under fluoroscopic
control. Care must be taken not to penetrate the
medial cortex. The osteotome is then used to PREOPERATIVE PLANNING
complete the osteotomy through the anterior and
Proximal tibial osteotomy is used to correct varus
posterior cortices, but should stop approximately
deformity of the knee and consists of a valgus
1 cm short of the medial cortex. The blade of the
osteotomy which may either be a lateral closing
osteotome can be marked at a level where
wedge or a medial opening wedge. The authors’
penetration of the far cortex will not occur and
preference is the medial opening wedge valgus
this marking can be observed carefully as the
osteotomy and is described below.
osteotome advances.
The osteotomy is then opened with distraction
osteotomes using a screwdriver under Indications
fluoroscopic control. When the osteotomy is
Proximal tibial osteotomy is indicated in the
opened, metal wedges can be gently inserted into
treatment of pain and deformity caused by varus
the osteotomy to the desired level. The amount of
osteoarthritis in relatively young patients when
correction can be checked with the image
non-operative management has failed.
intensifier using the alignment rod as previously
described. A locking plate with interposition
wedge of the desired size is then inserted into the Contraindications
osteotomy in the correct position and screws
• Distal lower limb ischaemia
inserted and checked with fluoroscopy. The
• Significant lateral or patellofemoral
opening wedge can be filled with bone graft or
osteoarthritis
calcium triphosphate wedges.
• Significant bone loss from the medial tibial
plateau
Closure • Flexion limited to less than 90°
• Fixed flexion deformity greater than 15°
Closure is performed in layers with continuous • Inflammatory arthritis
absorbable sutures and a continuous subcuticular • Osteoporosis
suture or staples to the skin. It is not usually • Inability to comply with rehabilitation
necessary to use a drain. protocol.
Proximal tibial osteotomy 195
Operative planning
Landmarks and incision
As for distal femoral osteotomy.
A medial opening wedge valgus osteotomy is
performed via an anteromedial approach to the
Anaesthesia and positioning proximal tibia. A longitudinal or oblique incision
is made over the anteromedial aspect of the
As for distal femoral osteotomy.
proximal lower leg in the region of the insertion of
the pes anserinus and 3 cm medial to the lower
SURGICAL TECHNIQUE border of the tibial tubercle.
wedge of the desired size is then inserted into the Fisher DE. Proximal tibial osteotomy 1970–1995.
osteotomy in the correct position and screws Iowa Orthop J 1998;18:54–63.
inserted and checked with fluoroscopy. The
opening wedge can be filled with bone graft or
calcium triphosphate wedges. Autograft is still KNEE ARTHRODESIS
advocated for larger corrections or revision
procedures. PREOPERATIVE PLANNING
Closure Indications
Closure is undertaken in layers with continuous The most common indication for knee arthrodesis
absorbable sutures and a continuous subcuticular is as a salvage procedure in failed revision knee
suture or staples to the skin. It is not usually arthroplasty either where infection has been
necessary to use a drain. resistant to eradication or when there is a non-
functioning extensor mechanism.
In the past and currently still in some parts of
POSTOPERATIVE CARE AND the world, knee arthrodesis is more commonly
INSTRUCTIONS performed in patients with post-infective arthritis,
tuberculosis, poliomyelitis and severe trauma.
Regular neurovascular observations should be
performed and the patient carefully monitored for
signs of compartment syndrome. Adequate Contraindications
analgesia is administered. Mechanical and chemical
• Critical arterial ischaemia
thromboprophylaxis is recommended. Two further
• Extensive bone loss (relative)
doses of prophylactic antibiotics are administered
• Ipsilateral hip arthrodesis (relative).
at 8 hours and 16 hours postoperatively. The
wound should be inspected and check radiographs
performed prior to discharge. If the fixation is Consent and risks
stable, range of motion exercises are encouraged
from day 1 postoperatively. Patients should remain • Infection (or failure to eradicate existing
non-weightbearing in a hinged knee brace for 2 infection)
weeks. Repeat radiographs are taken and clips • Bleeding
removed at this stage. Touch weightbearing only is • Venous thromboembolism
commenced in a hinged knee brace for a further 4 • Wound problems
weeks. If radiographs are satisfactory at 6 weeks, • Neurovascular injury
partial weightbearing can be commenced and if the • Fractures
osteotomy has united at 12 weeks the patient can • Delayed or non-union
build up to full weightbearing. • Pain
• Immobility
• Risk of subsequent amputation
RECOMMENDED REFERENCES
Brinkman JM, Lobenhoffer P, Agneskirchner JD, Operative planning
et al. Osteotomies around the knee: patient
selection, stability of fixation and bone healing in The indication for arthrodesis, severity of bone
high tibial osteotomies. J Bone Joint Surg Br loss and adequacy of soft tissue coverage all need
2008;90:1548–57. to be taken into account prior to deciding on
Coventry MB, Ilstrup DM, Wallrichs SL. Proximal whether the arthrodesis should be a single or
tibial osteotomy. A critical long-term study of staged procedure, an intramedullary or
eighty-seven cases. J Bone Joint Surg Am extramedullary fixation and whether it is
1993;75:196–201. necessary to enlist the help of a plastic surgeon.
198 Surgery of the knee
The patient should be thoroughly counselled approximately 15° of flexion, 7° valgus and 10°
before the operation. external rotation. Bone graft may be used if
desired. Compression must be achieved with the
Anaesthesia and positioning external fixator. Any form of external fixator can
be used, from simple monoaxial fixators to fine
See ‘Revision total knee replacement’ (p. 183). wire frames.
Intramedullary fixation
SURGICAL TECHNIQUE Bone cuts are made as above. The femoral and
tibial intramedullary canals are reamed. The distal
This depends on indication, type of fixation and
femur/proximal tibia can be reamed in a
need for bone grafting.
concave/convex fashion to increase contact
surface area. Fixation can be achieved either with
Landmarks and incision a long nail or with a two-part nail with a
locking device between the femur and tibia
A longitudinal, anterior midline incision is used, which can also provide compression and correct
usually through a previous total knee replacement alignment. The nail can be locked proximally and
scar. distally.
Dissection
Closure
The quadriceps tendon and patella tendon are
In some cases closure can be difficult.
split and a patellectomy performed. A
Occasionally, especially after repeated revision
synovectomy can be carried out and ligaments
cases or following infection, closure can be such a
released or divided to gain exposure.
challenge that it may even be necessary to
consider gastrocnemius muscle flap coverage and
Procedure skin grafting, where the assistance of a plastic
surgeon may be required.
The goals of arthrodesis are pain relief, eradication
of infection and sound bony fusion in the correct
alignment. In order to achieve these goals the
important factors are: good apposition of healthy POSTOPERATIVE CARE AND
bone surfaces, preservation of bone stock and INSTRUCTIONS
stable fixation with compression.
Implants are removed as described in the The amount of weightbearing allowed depends on
section ‘Revision total knee replacement’ (p. 185). the stability of fixation, but generally touch
It is important to preserve as much bone as weightbearing should be commenced immedi-
possible. Bone surfaces must be viable. In the ately, gradually built up to partial weightbearing
presence of infection, it is usually desirable to over approximately 6 weeks and to full
perform a two-stage procedure with the first weightbearing over the next 6 weeks.
stage involving thorough debridement, insertion
of an antibiotic-impregnated cement spacer and
temporary fixation. Second stage involves the RECOMMENDED REFERENCES
definitive arthrodesis. This is commonly achieved
in one of two ways. Conway JD, Mont MA, Bezwada HP. Arthrodesis
of the knee. J Bone Joint Surg Am 2004;86:835–48.
External fixation Wiedel JD. Salvage of infected total knee fusion:
The tibia is cut perpendicular to the long axis. The the last option. Clin Orthop Relat Res
femur is cut to enable apposition at 2002;(404):139–42.
Viva questions 199
Viva questions
1. What are the risks and complications of total 11. What extensile approaches are available in
knee arthroplasty? revision knee arthroplasty?
2. What are the contraindications to total knee 12. What is your rationale for choosing an implant
replacement? in revision knee arthroplasty?
3. Which total knee replacement would you 13. What are the treatment options for a 50-year-
choose and why? old man with medial compartment
osteoarthritis?
4. Discuss the advantages and disadvantages of
posterior collateral ligament retaining and 14. What criteria need to be met for a medial
sacrificing total knee replacement. unicompartmental knee replacement?
5. Describe how you would address an imbalance 15. How would you select the ideal patient for a
in flexion/extension gaps. patellofemoral replacement?
6. What releases would you perform to correct 16. How would you ensure adequate realignment
alignment in a valgus knee? in proximal tibial osteotomy?
7. How do you deal with a fixed flexion deformity 17. Why is a distal femoral osteotomy preferred to
during total knee replacement? proximal tibial osteotomy in a valgus knee?
8. What measures do you take to ensure correct 18. Discuss the pros and cons of opening versus
patella tracking in primary total knee closing wedge proximal tibial osteotomy.
replacement?
19. What are the indications for knee arthrodesis?
9. How would you manage a patient with a
20. Describe the general principles and fixation
painful knee replacement?
options in arthrodesis.
10. Describe the modes of failure of total knee
replacement.
12
Soft tissue surgery of the knee
Jonathan Miles and Richard Carrington
SURGICAL TECHNIQUE
Step Area of inspection Position of knee Position of arthroscope Structures to inspect Technical notes
1 Suprapatellar pouch 20° flexion Upright/upside down Synovium; loose bodies Turning the arthroscope through all angles
allows visualization of the synovium
throughout the whole cavity
2 Lateral gutter 20° flexion Upright Loose bodies Best inspected at this stage so that it is
not forgotten after tibiofemoral joint
inspection
3 Patellofemoral joint 20° flexion Upright/upside down Medial + lateral patella The arthroscope is turned upside down to
facets; synovial plica; inspect the patellar cartilage and kept
trochlea; patella tracking upright to view the trochlea. It must be
withdrawn to just inferior to the patella
to view tracking
4 Medial gutter 20° flexion Upright Loose bodies
5 Medial compartment 90° flexion initially Normal/viewing laterally Medial femoral condyle; Viewing the posterior horn is easier with
30° flexion to view the to improve visualization medial tibial plateau; the knee straighter and with the
posterior horn of the posterior horn medial meniscus; loose arthroscope swung to look laterally
bodies; creation of medial
portal
6 Intercondylar notch 90° flexion Upright Anterior cruciate ligament In ACL surgery, the portals are created a
(ACL); posterior cruciate little closer to the patella tendon to
ligament; loose bodies; improve access to the notch
both posterior horns
7 Lateral compartment Figure-four position Upright/viewing medially Lateral femoral condyle; Move the knee into the figure-four
lateral tibial plateau; position with the arthroscope in the notch
lateral meniscus; loose (Fig. 12.2). Drive into the lateral
Knee arthroscopy
bodies; popliteus tendon compartment as it opens and comes into
view.
203
204 Soft tissue surgery of the knee
PREOPERATIVE PLANNING
See ‘Knee arthroscopy’ (p. 200) for further details
of consent and operative planning, as well as
postoperative care.
Fig. 12.2 The figure-four position for lateral
compartment viewing
Indications
• Acute tears of the meniscus – radial,
longitudinal, complex and bucket-handle forms
(Fig. 12.3)
for 6 weeks. The wool and crepe are removed 24
• Degenerative tears of the meniscus (commonly
hours after surgery, to increase mobility. Sutures
posterior horn of medial meniscus)
are removed at 10–14 days after surgery.
• Meniscal repair – in non-degenerative,
longitudinal tears within 3 mm of the periphery
(i.e. within the vascular zone of the meniscus).
RECOMMENDED REFERENCES
Jaureguito JW, Greenwald AE, Wilcox JF, et al. SURGICAL TECHNIQUE
The incidence of deep venous thrombosis after
arthroscopic knee surgery. Am J Sports Med Partial menisectomy
1999;27:707–10.
Kim SJ, Kim HJ. High portal: practical philosophy Partial menisectomy is the most common
for positioning portals in knee arthroscopy. procedure performed by trainees throughout the
Arthroscopy 2001;17:333–7. developed world and is considered a required skill
Kramer DE, Bahk MS, Cascio BM, et al. Posterior by trainers and programme directors. It must be
knee arthroscopy: anatomy, technique, applica- part of a full diagnostic arthroscopy, as described
tion. J Bone Joint Surg Am 2006;88:110–21. in the previous section.
Initial inspection of the meniscus can often The meniscus can be resected using a number
reveal the presence, though not extent of a tear. of instruments. The author prefers to use simple
The smooth outline of the meniscus will be lost. punches for the majority of the resection and use
The first stage is to probe the meniscus with an an arthroscopic shaver to smooth over the final
arthroscopic probe. The probe is inserted under remnant. An ‘upbiter’ is very useful during
the meniscus and the hook turned to point resection of very posterior tears, particularly of the
upwards, into the meniscus; the probe is medial meniscus (Fig. 12.5).
withdrawn and will catch any inferior tear that The resection should be careful and
was not previously visible. methodical, leaving all stable meniscus behind.
Large posterior horn tears and even displaced After resection, the meniscus must be probed
bucket-handle tears can flip into the intercondylar again to ascertain that all remaining meniscus is
notch and will not be seen unless specifically stable.
looked for in the posterior part of the notch. Using
the probe, the surgeon can determine the extent Bucket-handle tear surgery
of the tear and decide on the boundary between
unstable, torn meniscal remnants and well-fixed, A bucket-handle tear is a large, longitudinal tear in
stable, meniscal rim (Fig. 12.4). which the internal portion is mobile and can flip
over and become stuck in the intercondylar notch.
It is three times as common in the medial as the
Medial femoral
condyle lateral meniscus. The following discussion uses the
medial meniscus as an example, though the
Torn medial principles are transferrable to the lateral meniscus.
meniscus Entry of the arthroscope into the medial
compartment can be difficult. Careful creation of
an anteromedial portal, as described, is
recommended, followed by use of a probe
Medial tibial plateau
through this portal to gently push the displaced
fragment medially. This will usually afford a good
view. Assessment can be made as to whether the
Arthroscopic tear is repairable (see the following section).
hook probe A probe is used to define the attachments of the
tear, both posteriorly and anteriorly (Fig. 12.6). A
Fig. 12.4 Use of an arthroscopic probe to show a punch is used to detach 90 per cent of the tear at
horizontal tear
Posterior
resection
Bucket
handle tear
Anterior
resection line
Fig. 12.5 An ‘upbiter’ is useful in posterior horn Fig. 12.6 Resection points of a bucket-handle medial
resection meniscal tear.
206 Soft tissue surgery of the knee
its posterior origin. It is easiest to do this with an Most surgeons recommended avoidance of
upbiter curved to the left for a left medial weightbearing for around 4 weeks after surgery,
meniscus and to the right for a right medial particularly avoiding weightbearing in flexion.
meniscus. A straight punch or side-biter is used to
resect completely through the anterior Discoid meniscus surgery
attachment. A strong, locking arthroscopic grasper
is introduced through the medial portal and Discoid malformation more frequently affects the
locked onto the middle of the torn remnant. The lateral meniscus and is bilateral in one-fifth of
remnant is removed with a ‘crocodile roll’ – the cases. The majority are stable, i.e. have peripheral
graspers are rolled over several times while attachments to the rim. These are treated by
carefully watching with the arthroscope. partial menisectomy, if symptomatic, to create a
Once the meniscal remnant has been freed, it is more normal meniscus.
removed through the medial portal. In large tears, If a discoid meniscus becomes suddenly painful,
this portal often requires enlargement. Careful it is likely that it is torn and should be examined
inspection of the meniscal remnant is carried out, and treated as such. The rarer unstable, or
with debridement of any further unstable tissue. Wrisberg variant, discoid meniscus is hypermobile
due to absent peripheral attachments. These are
Meniscal repair usually treated by complete excision as there is no
stable rim to leave in situ.
Repair is possible if the tear is within 5 mm of the
periphery, but more commonly undertaken if the POSTOPERATIVE CARE
tear is within 3 mm of the periphery, i.e. within
the vascular zone. In order to be worthy of repair, See ‘Knee arthroscopy’ (p. 200).
the tear should be between 8 mm and 30 mm long. Meniscal repair has a more controversial
The results of meniscal repair are better in rehabilitation regimen. The author uses a brace,
patients with a concurrent anterior cruciate limited to 0–60° range for 1 month then full range
ligament (ACL) reconstruction than in repair of motion within the brace for a further 2 months.
alone. Repair should not be undertaken in a knee Return to sports is gradual following the initial 3
with ligament injury that has not been repaired. A months in the knee brace.
variety of methods are described including
outside-in, inside-out and all-inside suturing (Fig. RECOMMENDED REFERENCES
12.7). In addition, meniscal darts can be used. The
details of this surgery are beyond the scope of this Fabricant PD, Jokl P. Surgical outcomes after
book. Sutures are placed, usually vertically, about arthroscopic partial meniscectomy. J Am Acad
3–4 mm apart from each other. Orthop Surg 2007;15:647–53.
Fig. 12.7 Meniscal repair: (a) outside-in; (b) inside-out; and (c) all-inside technique
Lateral patellar retinaculum release 207
Min S, Kim J, Kim LM, et al. Correlation between Anaesthesia and positioning
type of discoid lateral menisci and tear pattern.
Knee Surg Sports Traumatol Arthrosc See ‘Knee arthroscopy’ (p. 200).
2004;10:218–22.
Rankin CC, Lintner DM, Noble PC, et al. A Consent and risks
biomechanical analysis of meniscal repair
techniques. Am J Sports Med 2002;30:492–7. • The complications are essentially those of any
knee surgery: bleeding, infection, thrombosis and
numbness, whether carried out open or
LATERAL PATELLAR RETINACULUM arthroscopically
RELEASE • Mention of haemarthrosis should be made in
particular as it is very common and can be major
PREOPERATIVE PLANNING • Medial subluxation is a rare, late complication
chosen method. Occlusive dressing and heavy Mulford JS, Wakeley CJ, Eldridge JD. Assessment
wool and crepe bandages are applied. and management of chronic patellofemoral
instability. J Bone Joint Surg Br 2007;89:709–16.
Arthroscopic lateral release
Technique
A complete arthroscopy is carried out first – the
CARTILAGE RECONSTRUCTION
lateral release is done last as it causes bleeding. A SURGERY
tourniquet is not used as it interferes with patellar
tracking and causes more bleeding postopera- PREOPERATIVE PLANNING
tively.
A horizontal line is drawn laterally from the Indications
superior pole of the patella and another line 1 cm
away from the lateral border of the patella. A • Articular cartilage injury (most common on the
needle is inserted into the knee joint at the level medial femoral condyle)
where these lines cross. • Osteochondritis dessicans (most common on
the lateral part of the medial femoral condyle)
• Atraumatic osteonecrosis of the knee.
Structures at risk
• The superior geniculate artery Contraindications
The needle serves as a proximal limit of the release
to prevent damage to the artery and subsequent • Degenerative knee changes – none of the
bleeding that cannot be controlled arthroscopically. techniques developed to date are successful on
osteoarthritic lesions
• Age over 55 years – poor cartilage regeneration
Release is carried out, with cautery, running
and may be more suitable for arthroplasty
from the needle to the anterolateral portal; it is
techniques
continued until subcutaneous fat is seen from
• Active infection.
within the knee.
Closure
Consent and risks
The portals are closed with either single nylon
sutures or adhesive paper stitches. Adhesive • As for ‘Knee arthroscopy’ (p. 200)
dressings then wool and crepe are applied. • Unpredictable outcome (worse if longstanding
injury or high body mass index)
POSTOPERATIVE CARE AND • Donor site morbidity (mosaicplasty and
INSTRUCTIONS autologous chondrocytes transplants [autologous
Weightbearing is begun immediately. The wool chondrocyte implantation; ACI])
and crepe are removed after 24–36 hours and • Need for second procedure (ACI)
range of motion exercises are begun early (to
prevent lateral adhesions within the knee). The
patient is referred to physiotherapy to reinstate Operative planning
medial quadriceps exercises.
Details of previous imaging and surgery should be
RECOMMENDED REFERENCES available. Suitable equipment for the chosen
technique of chondroplasty consists of:
Kolowich PA, Paulos LE, Rosenberg TD, et al. • Microfracture picks / K-wire (microfracture)
Lateral release of the patella: indications and • Plug harvest and implant equipment (mosaic-
contraindications. Am J Sports Med 1990;18: plasty)
359–65. • Chondrocytes (ACI).
Cartilage reconstruction surgery 209
SURGICAL TECHNIQUE
Debridement
• Simple removal of loose chondral material and
smoothing of the damaged edges.
• ‘Roughening’ of the underlying, subchondral
bone may allow clot formation and encourage
fibrocartilage formation.
• May be suitable for small lesions. Fig. 12.9 Femoral condylar defect treated with
mosaicplasty
Microfracture
Following debridement, an awl is inserted into the
ipsilateral arthroscope portal and used to create peripheral areas of the superior trochlea, and
microfractures in the subchondral bone at the grafted into the defect until it is filled. Grafts are
defect (Fig. 12.8). The microfractures are 5 mm taken with a core drill and are 4–8 mm in
apart and approximately 5 mm deep. This allows diameter and 20 mm deep. Matching cores are
penetration of the tidemark and the release of removed from the defect and the graft plugs
pluripotential cells from the cancellous bone. This impacted in a mosaic pattern (Fig. 12.9).
produces a more pronounced and longer-lasting Care must be taken to leave the graft plugs
healing response than abrasion alone and increases flush with the surrounding cartilage. The defects
the prospect of fibrocartilage formation at the between the plugs fills in with fibrocartilage.
defect. Results are variable and highly dependent on the
skill of the surgeon. There are questions over its
Mosaicplasty use in defects over 4 cm2.
Small plug grafts are taken from a non- Autologous chondrocyte implantation
weightbearing area of the knee, typically the
Autologous chondrocyte implantation is
performed as a two-stage procedure. The first
stage is arthroscopic and includes a diagnostic
arthroscopy and debridement of any chondral
flaps around the area of chondral damage. This
should be done to provide a rim of stable or
healthy cartilage all around the lesion and is
essential for attachment of the graft. At the end of
the first stage arthroscopy, small segments of
healthy cartilage are harvested from the outer
border of the anterosuperior femur, usually on the
medial side of the trochlea. This is performed with
a small gouge to loosen the segment and rongeurs
to retrieve it. A venous blood sample is taken to
screen for infectious diseases.
Fig. 12.8 Microfracture of a chondral injury of the The chondrocytes can be prepared in a number
medial femoral condyle of ways and can be provided suspended in
210 Soft tissue surgery of the knee
Returning to the graft, the junction of bone and and the cortical margin of the graft facing
tendon of the femoral block is marked with a posteriorly in the tunnel. Inspection within the
surgical pen – the femoral block should be the knee will reveal when the marking on the femoral
smaller of the two. The two strong sutures in the plug has reached the margin of the femoral
femoral block are inserted into the eye of the tunnel. An interference screw guidewire is passed
guidewire and a Jacob chuck attached to the tip of anterior to the graft within the femoral tunnel to
the guidewire in front of the thigh. The guidewire a depth of at least 25 mm. An interference screw
is pulled through and the sutures recovered. A of appropriate size is then passed over the
second suture is passed through the tibial bone guidewire to secure the graft within the femur.
block – this should be either a strong, braided The position and security is checked by cycling
non-absorbable suture or a steel wire. the knee through flexion and extension several
The graft is firmly, but smoothly, pulled through times.
into position, keeping the knee at 90° of flexion The knee is held at 30–40° with the tibia in
slight external rotation, to secure the graft in the
tibia. While the graft is tensioned, a further
interference screw is inserted. The abolition of the
pivot shift phenomenon can be checked at this
stage. The graft saved from the tunnels is packed
into the defects in the patella.
Closure
The paratenon is closed with interrupted,
absorbable sutures over the tendon. The tendon
itself is not closed as this would shorten the
patella tendon. A small drain is inserted and the
skin is closed. Adhesive dressings then a wool and
crepe dressing are applied.
HAMSTRING, ARTHROSCOPIC
TECHNIQUE
Landmarks
Fig. 12.14 Drilling the femoral tunnel through the tibial • Tibial tuberosity
tunnel • Patellar tendon.
214 Soft tissue surgery of the knee
Whip stitching
created graft harvest incision. With the transfix screw. The Beath pin is left captured within
arthroscope in the anterolateral portal, the tibial the guide in the femoral tunnel. A thin wire is
tunnel guidewire is inserted and its entry point passed over the end of the Beath pin and then
into the knee confirmed to be within the posterior pulled through the femur and the guide, using a
portion of the tibial stump on the tibial surface. handle attached to the Beath pin medially. When
The tibial tunnel is then drilled and any debris at the guide is pulled out of the femoral tunnel, the
its entrance into the knee cleared with an guidewire is pulled with it, through the tibial tunnel
arthroscopic shaver. The guidewire is then drilled and out of the anterior tibial cortex (Fig. 12.17).
into the correct position in the lateral wall, as in The graft can be looped over the wire and the
the B-T-B technique.. This is again drilled to two ends of the wire pulled apart to introduce the
30–35 mm depth, debris is removed and the graft, through the tibial tunnel and into the
posterior margin of the tunnel is checked. femoral tunnel. When the wire passes freely from
The guidewire is threaded with the sutures side to side, the graft has been fully advanced. A
from one end of the graft and pulled through the transfix pin passed over the wire, which is held
skin. The graft is pulled into place, until the 30 tight, will now pass through the loop in the two
mm of whip stitch has entered the femoral tunnel, graft strands, thus fixing it in the femoral tunnel
as viewed with the arthroscope. The graft can be (Fig. 12.18).
fixed in situ with an interference screw, with a The position of the graft is checked
similar technique to that described in ‘B-T-B graft, arthroscopically and the graft fixed in the tibial
open technique’ (p. 211). tunnel as described in ‘B-T-B graft, open
Alternatively, a transfixion pin method can be technique’ (p. 211).
used to introduce and fix the graft in the femoral
tunnel. In this method a transfix guide is inserted 30 Closure
mm into the femoral tunnel and the cannulated
guide is advanced to the lateral aspect of the thigh. Closure of wounds is with a combination of
The skin and iliotibial band are incised and the interrupted, absorbable deep sutures and the
cannulated guide advanced to the lateral femur. A surgeon’s chosen skin closure. The arthroscopy
Beath pin is drilled through the guide, through the portals and exit wounds of guidewires can be
femur and out through the medial skin. The closed with adhesive paper closure sutures alone.
cannulated guide and sidearm are removed and the Adhesive dressings and a wool and crepe dressing
lateral cortex is drilled to accept the head of the are applied.
Fig. 12.17 (a) Wire is advanced through femoral tunnel, (b) graft introduced into the femur and (c) transfix pin
passed through the graft
216 Soft tissue surgery of the knee
POSTOPERATIVE CARE AND used to keep the thigh and calf musculature
INSTRUCTIONS optimal.
The patient is not put into a brace, rather early RECOMMENDED REFERENCES
supervised range of motion exercises are begun. A
drain, if used, is removed at 24 hours after surgery. Frank CB, Jackson DW. Current concepts review –
At this time the bulky dressing is removed, leaving the science of reconstruction of the anterior
adhesive dressings over the wounds. With the aid cruciate ligament. J Bone Joint Surg Am
of a physiotherapist, range of motion exercises are 1997;79:1556–76.
begun. The patient can be discharged once they Salmon LJ, Russell VJ, Refshauge K, et al. Long
have achieved a range from 0–90°. The wounds term outcome of endoscopic anterior cruciate
are inspected and sutures removed at 2 weeks ligament reconstruction with patellar tendon
after surgery. autograft. Am J Sports Med 2006;34:721–32.
The physiotherapist supervises gentle exercise, Williams RJ, Hyman J, Petrigliano F, et al. Anterior
using closed chain exercises only for the first 6 cruciate ligament reconstruction with a four-
weeks. After 6 weeks, the use of a rowing machine strand hamstring tendon autograft. J Bone Joint
and exercise bike is permitted. The range of Surg Am 2004;86:225–32.
motion is increased up to full at around 12 weeks. Woo SL, Kanamori A, Zeminski J, et al. The
After this period more aggressive exercise can effectiveness of reconstruction of the anterior
begin. Running is not permitted for the first 3 cruciate ligament with hamstrings and patellar
months and contact sports not for the first 8 tendon: a cadaveric study comparing anterior
months after surgery. The use of proprioceptive tibial and rotational loads. J Bone Joint Surg Am
exercises is encouraged and maintenance exercises 2002;84:907–14.
Viva questions
1. What equipment is required to perform a 10. What are the common indications for cartilage
diagnostic arthroscopy? reconstruction surgery?
2. Define the anatomy of the posterior knee 11. Describe the procedure of microplasty to the
arthroscopy portals. medial femoral condyle.
12. What are the advantages of autologous
3. Which structures are at risk in the posterior chondrocyte implantation over microplasty?
portals for knee arthroscopy?
13. How are the cells provided for autologous
4. What are the indications for meniscal repair? chondrocyte implantation?
5. Which techniques do you know for meniscal 14. What risks do you describe to a patient
repair? consenting for anterior cruciate ligament
reconstruction?
6. How are discoid lateral menisci classified?
15. Describe the anatomy of the pes anserinus.
7. What treatment do you use for a discoid lateral
meniscus? 16. How are the hamstrings harvested for an
anterior cruciate ligament graft?
8. Which associated anatomical findings worsen a
tight lateral retinaculum? 17. What is the minimal acceptable graft thickness
9. What are the advantages and disadvantages of for anterior cruciate ligament reconstruction?
arthroscopic over open lateral release?
Viva questions 217
18. Where are the isometric points for the origin 20. Describe your postoperative regimen after
and insertion of an anterior cruciate ligament anterior cruciate ligament reconstruction.
graft?
19. What position is the knee held in while an
anterior cruciate ligament graft is tensioned
and fixed?
13
Surgery of the ankle
Laurence James and Dishan Singh
Contraindications
Anaesthesia and positioning
• Infection
• Degeneration of subtalar and midfoot joints. This is performed as for ankle replacement.
Ankle arthrodesis 219
Ankle
fusion
Figure 13.1 Arthrodesis with screw fixation Figure 13.2 Arthrodesis with nail fixation
220 Surgery of the ankle
Closure Contraindications
A layered closure is followed by the surgeon’s • Ankle joint infection
choice of skin closure for open techniques. Nylon • Avascular necrosis of a large part of the talar
to skin is used to close arthroscopic fusion portals. body
• Severe deformity that would not allow for good
POSTOPERATIVE CARE AND biomechanical function and lead to greater
INSTRUCTIONS wear of the ultrahigh molecular weight
polyethylene (UHMWPE) insert (greater the
Thromboembolism should be prevented by early 15° varus/valgus deformity)
mobilization and the addition of chemical or • Poor soft tissues
mechanical measures in patients at increased risk. • Heavy manual occupation.
Two more doses of the antibiotic given at
induction should be given at 8 hours and 16 hours
after surgery. Consent and risks
Early mobilization is non-weightbearing, with • Loosening: revision surgery is required for
the aid of crutches. Radiographic signs of union loosening in up to 10 per cent at 10 years
are sought before unprotected full weightbearing (approximately).
is allowed; this often takes around 3 months. • Malpositioning
• Fracture: up to 10 per cent though they fare well
RECOMMENDED REFERENCES with appropriate identification and management.
Buck P, Morrey BF, Chao EY. The optimum • Wound problems, pain and stiffness: 5 per cent
position of arthrodesis of the ankle. J Bone Joint • Deep vein thrombosis (DVT)/pulmonary
Surg Am 1987;69:1052–62. embolism/infection: 1 per cent
Kitaoka HB, Patzer GL, Felix NA. Arthrodesis for
the treatment of arthrosis of the ankle and
Operative planning
osteonecrosis of the talus. J Bone Joint Surg Am
1998;80:370–9. Assessment of the soft tissues, as well as vascular
Mann RA. Arthrodesis of the foot and ankle. In and neurological examination are mandatory on
RA Mann and MJ Coughlin (eds). Surgery of the the day of surgery. Recent weightbearing
Foot and Ankle. St Louis: Mosby Year Book, 1993. radiographs must be available.
Mann R, Rongstad AM. Arthrodesis of the ankle: a Availability of the implants and operative sets
critical analysis. Foot Ankle Int 1998;19:3–9. must be checked by the surgeon. Prophylactic
Scranton PE. An overview of ankle arthrodesis. antibiotics are administered on induction (the
Clin Orthop Relat Res 1991;268:268–96. antibiotic of choice depends on local policy, but a
common choice is cefuroxime).
proof drapes are used with adhesive edges to implant positioning are the same. In general terms,
provide a seal to the skin. an extramedullary guide is placed on the anterior
surface of the tibia, in line with the crest and
SURGICAL TECHNIQUE passing though the line of the second metatarsal
ray distally – anatomical axis. This is strapped in
Landmarks place. The joint line is then identified and a fin is
placed between the talus and tibia through the
These should be marked preoperatively: centre of the cutting block. Pins are used to fix the
• Tendons – tibialis anterior, extensor hallucis cutting guide to the tibia. This block ensures
longus, extensor digitorum longus parallel cuts in the distal tibia and talar dome,
• Dorsalis pedis – note: this is absent in 10 per without altering the joint line height –
cent of the population approximately 2–3 mm is resected from each
• Cutaneous branches of the superficial peroneal surface. Guides then size the tibial and talar
nerve (variable course). components, such that an appropriate sized
window and accurate anterior and posterior
Incision chamfer cuts are made to the tibia and talus,
respectively. Trial components and spacer (to
The anterior approach to the ankle is used. The assess stability and range of movement) are used
skin is incised in the midpoint between the medial prior to actual prosthesis placement.
and lateral malleoli – from 3 cm above, extending Pitfalls to avoid include:
5 cm below the palpable ankle joint and avoiding • Varus/valgus positioning of tibial and talar
cutaneous nerves where encountered. cutting guides, which can also lead to abnormal
saggital plane tilting – early loosening.
Dissection • Anterior/posterior placement of talar or tibial
components – early loosening.
• Notching of medial and lateral malleoli during
Structures at risk
tibial cuts – fracture.
• Dorsalis pedis artery • Fracture of the anterior tibial cortex when
• Deep peroneal nerve creating window to allow for tibial post during
insertion of component.
dissection (with a clip) used to breech the ankle • Anteromedial portal – this lies medial to tibialis
joint, thereby avoiding damage to the superficial anterior. The joint line is initially identified by
nerves – unlike knee arthroscopy where a blade is palpation and then a white needle is inserted
passed directly into the joint. into the joint to confirm the level. The needle is
directed slightly superiorly to pass over the talar
Creation of portals dome. The arthroscope and introducing trochar
should be able to be swept across the joint from
medial to lateral.
Structures at risk • Anterolateral portal – this lies lateral to
extensor peroneus tertius and the neurovascular
• Nerves: deep peroneal, superficial peroneal bundle (dorsalis pedis and deep peroneal
branches, sural, tibial nerve), avoiding the superficial nerves marked
• Arteries: dorsalis pedis, posterior tibial artery out preoperatively. The light source within the
joint can be used as a guide, this will also help
A number of portal sites are described (Fig. 13.3). to identify the dorsal lateral branch of the
The central anterior portal is best avoided because superficial peroneal nerve which is at risk. A
of a high risk of neurovascular damage. white needle is inserted as outlined above
• Posterolateral portal – this is located lateral to
the Achilles tendon 1 cm above the tip of fibula.
Insert prior to posteromedial portal – risk of
Antero-medial sural nerve damage.
portal • Posteromedial portal – this is just medial to
Antero-central Achilles tendon at the level of the
portal
posterolateral portal. Flexor hallucis longus is
Antero-lateral
used to sweep away the tibial nerve and
portal
Tibialis ant.
posterior tibial artery – the main structures at
risk.
EHL
Posterior portals are not as frequently used
EDL and
peroneus (because of the increased risk of neurovascular
tertius damage), but are helpful in visualizing the
posterior ankle and subtalar joints.
Procedure
A systematic approach is essential if pathology is
not to be missed. Initially the whole of the talar
dome is inspected – ankle plantar flexion aids
visualization of the posterior dome. The talar neck
is then examined. Pathology on the corresponding
articulating surface of the tibia is also documented,
as well as the anatomy of the anterior aspect of
tibia. The medial and lateral gutters are then
inspected. Key features to identify include:
• Medial malleolus
• Deltoid ligament
• Lateral malleolus
• Anterior and posterior tibiofibular ligaments
Figure 13.3 Typical portal positioning (anterior above • Anterior talofibular ligament
and posterior below) • Syndesmosis.
224 Surgery of the ankle
Closure Indications
Non-absorbable suture is used to close the skin Diagnosis is key. There are three common patterns
incisions. of tendon pathology:
• Overuse (non-insertional) tendinopathy – this
POSTOPERATIVE CARE AND has a gradual onset classically with morning
INSTRUCTIONS pain and stiffness that eases with activity and
reoccurs at rest later. Associated with an
The patient is fully weightbearing – as tolerated – increase in activity, change of surface or change
unless the patient has a microfracture of an of footwear/poor footwear.
osteochondral defect, where range movement is • Partial and complete ruptures – there is a
encouraged in a non-loading manner so as to sudden onset of severe pain, marked disability
protect the developing fibrocartilage plug. and these ruptures are 10 times more common
Specific precautions are rarely required. in males. With peak incidence in the 30s and
40s. Patients often describe hearing a ‘pop’ and
RECOMMENDED REFERENCES feel an impact in the back of the leg or heel.
• Insertional tendinopathy (enthesopathy) – this
Ferkel RD, Karzel RP, Del Pizzo W, et al.
can be mistaken for a number of pathologies
Arthroscopic treatment of anterolateral
including retrocalcaneal bursitis, Hagland
impingement of the ankle. Am J Sports Med
disease (painful retrocalcaneal bursitis and a
1991;19:440–6.
bony prominence), Achilles bursitis.
Ferkel RD, Zanotti RM, Komenda GA, et al.
Be aware of the systemic enthesopathies/
Arthroscopic treatment of osteochondral lesions
rheumatoid arthritis and spondyloarthro-
of the talus: Long-term results. Am J Sports Med
pathies; it is an area where misdiagnosis is
2008;36:1750–62.
common and the differential diagnoses include:
Niek van Dijk C, van Bergen CJ. Advancements in
– Posterior ankle impingement syndrome
ankle arthroscopy. J Am Acad Orthop Surg
– Accessory soleus
2008;16:635–46.
– Deep posterior compartment syndrome
Tryfonidis M, Whitfield CG, Charalambous CP, et
– Sever’s disease
al. Posterior ankle arthroscopy portal safety
– Stress fracture
regarding proximity to the tibial and sural nerves.
– Inflammatory arthropathy
Acta Orthop Belgica 2008;74:370–3.
– Neurogenic referred pain.
PREOPERATIVE PLANNING
Consent and risks
There is an ever increasing incidence of tendon
problems, most commonly seen in recreational • 12 per cent complications (54 per cent wound
runners (racket sports, track and field, volleyball related)
and football) and competitive runners, who are 88 per cent return to function after a 6- to 12-
10 times more affected than age-matched month treatment programme.
controls.
Despite preventive measures, 7–8 per cent of
top level athletes experience the problem at some Operative planning
stage in their career. The long-term prognosis is
good with 84 per cent fully recovered at 8 years;
Non-operative management
94 per cent remain asymptomatic. Once the diagnosis has been made, consideration
Surgery for Achilles tendinopathy 225
is given to whether operative treatment is the best described here, as an example. Ancillary
option for the patient. These include: procedures can be used to augment treatment;
• Older patients and those with low activity levels their details are beyond the scope of this book. The
• Those able to tolerate a rehabilitation regimen, procedures include: calcaneoplasty, bursectomy,
which have an overall success rate of 75–85 per osteotomy and debridement of the tendon.
cent.
• Achilles rupture with a 10 mm gap when the
ankle is in neutral and complete apposition of
Landmarks
the ends with plantar flexion on ultrasound; • Midpoint of the calcaneal tuberosity posteriorly
treatment with 3 cm of hindfoot elevation for 8 where tendo-Achilles inserts
weeks in a below knee cast and then a 1 cm • Medial and lateral aspects of tendon traced
elevation for an additional 3 months (75 per proximally to bellies of gastrocnemius to
cent rate of return to normal function). identify aponeurosis.
Poor outcomes occur in 17.5 per cent, these
include: Incision
• Ongoing pain
• Lengthening dysfunction
• A reduced calf size Structure at risk
• Re-rupture in 6.4 per cent.
• Sural nerve
For tendinopathies in the absence of rupture con-
servative management should include eccentric
heel drops (Alfredson’s painful eccentric heel-drop A 5–10 cm incision is created (at the level of the
protocol): defect) along the medial border of the Achilles
• Three sets of 15 repetitions twice daily, 7/7, for tendon. This avoids the sural nerve and allows
12 weeks access to plantaris.
• Exercise until pain free then add load to create
pain (up to 60 kg). Dissection
There is a 90 per cent cure rate.
Bursae are treated with non-steroidal anti- • Directly deepen to paratenon.
inflammatory drugs (NSAIDs), intrabursal • Open paratenon and debride tendon.
cortisone injections and deep friction massage. • Thick flaps are vital for healing.
Biomechanical treatment includes heel lifts. Other
treatments include sclerosant injections, nitric Procedure
oxide, corticosteroids and electrophysical agents.
It is necessary to address peritendinous adhesions
Operative management and excise intratendinous lesions. A modified
A rapid return to function and reduced long-term Kessler box suture is recommended. This consists
pain. of two standard Kessler sutures, at 90° to each
other, ensuring the ends are tied inside not
Anaesthesia and positioning outside. It is best to use 1/0 PDS: this ensures
good strength and slides easily. The repair is
• General anaesthesia with local infiltration.
completed with a continuous epitendinous suture
• Thigh tourniquet.
(3/0 Vicryl). A number of techniques are
• Prone position with ankles resting of pillow.
described for repair of tendon defects, including:
SURGICAL TECHNIQUE • Turn down flaps – this involves a centrally based
fascial flap developed from the proximal
There is much debate about open versus segment and turned distally though 180° before
percutaneous repair. The open technique is suturing.
226 Surgery of the ankle
Closure
Closure is performed in thick layers with a non-
absorbable suture for the tendon repair.
Absorbable suture is used for the paratenon and SURGERY FOR PERONEAL
skin closure.
TENDINOPATHY
POSTOPERATIVE CARE AND
INSTRUCTIONS PREOPERATIVE PLANNING
Initially immobilize in equinus cast with strict The peroneus longus originates from the lateral
elevation and neurovascular observation. This is tibial condyle and head of fibula to insert on
followed by 6 weeks’ non-weightbearing with the first metatarsal base and medial cuneiform.
serial casting to return the ankle to a plantigrade The peroneus brevis originates from the middle
position. At 6 weeks, conversion to a removable one-third of the fibula and tibia to insert on the
boot allows the patient to fully weightbear and base of the fifth metatarsal. Remember, at the
commence physiotherapy for another 6 weeks. ankle the peroneus brevis is sandwiched
The functional outcome is assessed in clinic at 3 between bone and the peroneus longus – ‘brevis to
months. bone’.
• Deepening of the peroneal groove – using a 4.5 Oyedele O, Maseko C, Mkasi N, et al. High
mm drill, a longitudinal hole is made in the incidence of os peroneum in cadavers. Clin Anat
posterior third of the tip of fibular, then the 2005;19:605–10.
posterior cortex is ‘stoved in’ to deepen the Porter D, Torma J. Peroneal subluxation in
peroneal groove. The retinaculum is then athletes. Foot Ankle Int 2005;26:436–41.
repaired and a calcaneal osteotomy can be
performed if required. The tendons can also be
rerouted behind the calcaneofibular ligament as
an alternative to the deepening procedure.
• A partial thickness distal fibular osteotomy –
this is rotated posteriorly (Kelly procedure).
• Distal fibular sliding graft (Duvries
modification) can also be carried out (Fig.
13.5).
Viva questions
1. What are the indications, benefits and 7. How do you perform an ankle arthroscopy?
drawbacks of ankle arthrodesis?
8. What are the complications of ankle
2. What are the treatment options for a 40-year- arthroscopy and how can they be minimized?
old man with symptomatic osteoarthritis of the
9. How would you fuse an ankle?
ankle?
10. Describe the follow up and complications you
3. Describe the anatomy of anterior ankle
might expect following ankle arthrodesis?
arthrotomy?
11. What types of ankle arthroplasty are you aware
4. What complications do you warn the patient
of?
about prior to ankle replacement? What are
their incidences? 12. What are the principles of the prosthesis used?
5. What are the contraindications to ankle 13. Describe the technique of ankle arthroplasty.
replacement?
14. What are the common pitfalls and how can
6. Describe the portals used in arthroscopy. they be avoided?
Surgery for peroneal tendinopathy 229
15. Describe an approach to the peroneal tendons. 19. How might you augment a tendo-Achilles
repair, e.g. in a patient with tendon
16. How might you address peroneal tendon
loss/shortening?
subluxation operatively?
20. What are the common indications for operative
17. What is the most common approach to the
management of peroneal and Achilles tendon
Achilles tendon?
disorders?
18. Describe the technique for direct repair of the
Achilles tendon?
14
Surgery of the foot
Simon Clint and Nick Cullen
Principles of foot and ankle arthrodesis 230 Lesser toe deformities 246
Hallux valgus correction 232 Lesser metatarsal (Weil) osteotomy 249
FIrst metatarsophalangeal joint cheilectomy 241 Fifth toe soft tissue correction (Butler procedure) 250
First metatarsophalangeal joint arthrodesis 242 Hindfoot arthrodesis 252
Ingrowing toenail surgery 244 Calcaneal osteotomy 255
Interdigital neuroma 245 Viva questions 257
SURGICAL TECHNIQUES
Given the huge range of surgical procedures
described for hallux valgus, it is not within the
scope of this book to describe them all. We shall
therefore concentrate on those procedures
commonly performed. Each procedure is
described individually but in practice several
techniques, such as the metatarsal osteotomy,
Akin osteotomy and lateral soft tissue release, may
Incongruent joint Congruent joint
be performed in combination.
Figure 14.2 Assessment of first metatarsophalangeal
joint congruity
Dissection is continued down to capsule and adductor hallucis into the phalanx. The insertion
then a dorsal flap is carefully elevated to of adductor hallucis is released from the phalanx
identify the dorsal nerve adherent to the capsule then, working proximally, the remaining tendon is
on the dorsomedial aspect. This is repeated released from the sesamoid. Deep to this is the
on the plantar side, dissecting around the capsule inter-metatarsal ligament which runs from the
to create a small pocket. A longitudinal second metatarsal to the lateral sesamoid, not the
capsulotomy is performed and any adhesions first metatarsal itself. This is carefully divided from
released. the sesamoid, taking care to preserve the
neurovascular bundle which lies directly
Surgical technique underneath. The lateral capsule (metatarso-
Unless a distal metatarsal osteotomy is also to be sesamoid ligament) is then incised longitudinally,
performed, the prominent medial eminence of the after which the articular surface of the lateral
head can now be removed. This is done with a fine sesamoid can be inspected and should be
oscillating saw, aiming to cut in line with the reducible underneath the metatarsal head. The
medial shaft starting 2–3 mm from the medial retractor is removed and confirmation that the toe
sulcus (Fig. 14.3). can be passively overcorrected is sought.
Attention is now turned to the first web space. Returning to the medial side, the metatarsal
A 3 cm incision is centred between the metatarsal head should be reducible onto the sesamoids. If
heads in the first web space then bluntly too much resistance is encountered, a bony
dissecting down to the level of the heads. Inserting procedure is required to correct the deformity.
a laminar spreader or self-retainer between the Subsequent capsular plication is designed to take
heads allows identification of the lateral sesamoid in excess capsule, not pull the sesamoid complex
and the insertion of adductor hallucis into its over.
lateral edge. Using a size 15 blade, the capsule is Using an absorbable suture, the excess capsule
released from the dorsal aspect of the sesamoid is ‘double-breasted’ while holding the MTPJ
then the blade advanced to the insertion of flexed. This is done by passing a stitch through the
dorsal capsule from outside, medial to the
extensor tendon and avoiding the identified nerve.
The needle is then passed from outside the plantar
capsule, just medial to the sesamoid then reversed
to come from inside out. It is finished by exiting
through the dorsal capsule, near the earlier entry
point. As the suture is tightened, the dorsal
capsule should double-breast over the plantar
capsule. Plication is checked to ensure that it is
not too tight by flexing and extending the joint.
Closure
Medial sulcus The rest of the capsule is then closed with
absorbable sutures prior to skin closure.
Scarf osteotomy
The scarf osteotomy is a powerful and versatile
osteotomy allowing correction of all of the axes of the
hallux valgus deformity; it is a technically
challenging procedure with a steep learning curve. It
Figure 14.3 Excision of medial eminence of first is named after a joiners’ technique, used to connect
metatarsophalangeal joint two beams.
236 Surgery of the foot
10 mm 5 mm
3 mm
3 mm
medial point of origin of the distal first metatarsal the proximal fragment can be bevelled flush with
cut running perpendicular to the second the shaft.
metatarsal shaft and on through the lateral rays
the metatarsal head that it passes through (usually Closure
the fourth) can be used as a reference for the cut. Closure of the capsule should be performed as
Palpating the fourth metatarsal head, another line described previously.
is drawn on the dorsal surface, from the distal arm
across the dorsal surface towards the fourth.
Once satisfied with the planned osteotomy, an Akin osteotomy
oscillating saw is used to score the cortex for the
longitudinal arm. After a starting point is made,
Specific indications
the blade is angled plantarwards, in the plane of • Hallux inter-phalangeus deformity, where the
the shafts of the metatarsals. Maintaining this deformity occurs distal to the MTPJ
angle, the whole length of the longitudinal arm is • In combination with a metatarsal osteotomy to
cut, penetrating only the medial cortex; the lateral correct residual phalangeal deformity.
cortex is then softly cut in the same plane. Next
the distal arm is cut, maintaining the slight plantar
Specific contraindications
angle and aiming for the fourth metatarsal head as Akin osteotomy in isolation will not correct joint
planned. The proximal cut should now be cut incongruity or an increased IMA so should not be
parallel or slightly divergent to this – if the cuts used alone in these cases.
converge, the osteotomy will not displace. The
osteotomy should now be mobile. If not, all cuts
Incision
are checked for completion and the two fragments A medial longitudinal incision is performed,
gently freed with a MacDonald dissector, starting starting just proximal to the interphalangeal joint
proximally. (IPJ) and extended past the medial eminence of
The osteotomy is now displaced as required. the metatarsal. This can be incorporated into the
This is facilitated by a ‘push–pull’ action, grasping incision for a metatarsal osteotomy if required.
the proximal fragment with a towel-clip while
pushing the distal fragment laterally. The
Dissection
osteotomy should displace laterally and A longitudinal capsular incision is made and
plantarwards. The reduction is then held with a extended proximally to incise the periosteum of
clamp. The reduction is checked by observing the the phalanx. This is then carefully elevated,
position of the medial sesamoid: it should lie allowing the placement of retractors superiorly
under the medial metatarsal head. Once the and inferiorly.
reduction is satisfactory, a K-wire is inserted along
the lateral edge of the proximal fragment into the
Surgical technique
head and a stepped bone clamp will prevent
displacement. Structure at risk
The osteotomy is secured with two screws –
• Flexor hallucis longus tendon
headless, variable pitch compression screws are
ideal. The first screw should start from the
dorsolateral aspect of the distal end of the If required, the medial eminence of the metatarsal
proximal fragment and aim towards the medial can be excised, as above. The osteotomy is a closing
sesamoid. This must be intraosseous to avoid wedge osteotomy, performed with an oscillating
sesamoid damage. A second screw can then be saw from the medial side; the lateral cortex is left
used in a dorsoplantar direction to secure the intact. Particular care should be taken to avoid
proximal extent of the osteotomy. The proximal damage to the long flexor inferiorly. It is easy to
screw should be bicortical. overcorrect the deformity, so it is wise to
After fixation, the prominent medial cortex of underestimate the size of the wedge and check the
238 Surgery of the foot
Osteotomy for staple fixation Osteotomy for screw fixation Figure 14.6 Akin osteotomy
result. The alignment of the osteotomy depends on • Congruent hallux valgus deformity as the
the planned means of fixation (Fig. 14.6). osteotomy does not disturb the balance of the
If a staple is used, the first cut should be parallel joint – using a biplanar chevron (see below).
to the proximal joint surface. The second cut is
parallel to the base of the nail, aiming to converge Specific contraindications
before the lateral cortex, leaving it intact. The Due to technical limits of the procedure, it should
wedge is removed and the osteotomy closed. If be reserved for deformities with an IMA <12°
there is resistance, the lateral cortex can be HVA <30° and DMMA <15°. Attempting to push
cautiously weakened with the saw, but should not the indications further increases the risk of
be breached. Using the planned staple as a guide, avascular necrosis of the capital fragment.
entry holes are drilled using a fine K-wire and the
staple inserted. After insertion the joint is
Consent and risks
inspected to ensure that it is not penetrated by the
staple. Postoperative radiographs can be • Avascular necrosis of the capital fragment: up to
misleading in this regard because of the convex 20 per cent in some series. Probably technique
nature of the joint surface. dependent with increased avascular necrosis
If a cannulated compression screw is to be used, seen with extensive soft tissue stripping and
the osteotomy will be angled to allow release and with excessive displacements
compression. A screw will be inserted over a attempted
guidewire passing from the medial edge of the • Malunion: if the osteotomy is angled too
proximal flair of the phalanx, exiting distally in proximally, shortening of the first metatarsal will
the lateral cortex. occur with translation. Similarly, if the
osteotomy is angled dorsally the metatarsal head
Closure will be elevated. Both of these technical errors
The capsule is closed with absorbable sutures prior will alter the relationship of the first metatarsal
to skin closure. A forefoot dressing is applied. head to that of the lesser metatarsals and may
lead to transfer metatarsalgia
Chevron osteotomy
Incision and dissection
The chevron osteotomy is a relatively simple
osteotomy for the correction of mild hallux A standard medial approach is made to the
valgus. metatarsal head (see above).
Closure
Capsular closure is as above.
(b)
Lapidus procedure
Figure 14.7 Chevron osteotomy. (a) Classic chevron
Specific indications
osteotomy, risking damage to plantar blood supply to
metatarsal head. (b) Modified chevron osteotomy to • Hallux valgus deformity in the presence of
preserve plantar blood supply to metatarsal head instability of the first TMTJ
• Moderate to severe incongruent hallux valgus
deformity
• Salvage procedure for previous failed hallux
valgus surgery
• Arthritis of the first TMTJ.
beginning at the sulcus. A lateral release is not
routinely performed due to the increased risk of
Specific contraindications
avascular necrosis. The chevron osteotomy is a V- Given the shortening of the first ray that occurs
shaped cut of approximately 60° with the apex at with Lapidus, the procedure should not be
the centre of the metatarsal head (Fig. 14.7). performed on patients with short first metatarsals.
Because the plane of the cuts is crucial, it can be
useful to place a K-wire in this central point,
Surgical technique
running parallel to the sole of the foot and the
distal articular surface of the metatarsal. This wire Structure at risk
can be then be used as a cutting guide to position
• Tibialis anterior tendon
the limbs of the chevron. The most crucial cut is
the plantar limb, which must exit the plantar
surface of the metatarsal in an extra-articular The Lapidus procedure involves first TMTJ
position to avoid damage to the sesamoid arthrodesis; this should be performed with the
articulation. Several authors advocate a more previously described lateral soft tissue release,
horizontal plantar limb (see Fig. 14.7) to attempt excision of the medial eminence and plication of
to preserve the plantar blood supply (see ‘Scarf the medial capsule. The medial incision for the
osteotomy’ above). The dorsal limb is then cut at MTPJ can be continued proximally to the TMTJ.
approximately 60° to the first cut. After Alternatively, a separate medial incision can be
completion of the cuts, the capital fragment can made centred over the joint. The joint is usually
be translated laterally by up to 30 per cent of its deep to a vein, crossing from dorsal to plantar and
width to correct the hallux valgus. some authors advocate preserving it to reduce
240 Surgery of the foot
postoperative swelling. The joint can be identified Otherwise a non-weightbearing cast can be used
with the aid of a needle and opened to mobilize to protect the arthrodesis.
the joint. Care must be taken to avoid damage to
the tendon of tibialis anterior, which lies on the Proximal (basal) metatarsal osteotomy
inferomedial aspect of the joint. Using traction on
the toe, the joint can be opened and preparation The proximal metatarsal osteotomy is usually
of the joint performed as detailed in ‘Principles of performed in combination with a lateral soft
foot and ankle arthrodesis’ (p. 230). Once the tissue release, excision of medial eminence and
preparation has begun, there is enough room to medial capsule closure, as described above.
insert a laminar spreader.
Several authors describe a Lapidus procedure as Specific indications
a closing wedge arthrodesis. However, this is Correction of moderate to severe hallux valgus,
usually not required. By careful preservation of especially when associated with a large IMA. By
the joint shape the base of the metatarsal can making an osteotomy at the base of the
usually be displaced medially and slightly metatarsal, larger corrections of IMA can be made
inferiorly with digital pressure, thereby reducing than by operating more distally.
the IMA and overcoming the elevation of the
metatarsal head caused by shortening of the joint. Specific contraindications
A good correction coincides with the appearance
Congruent deformities (if used in isolation) – as
of a ‘step’ on the medial side. Once reduced, the
the osteotomy does not alter the relationship
joint is provisionally held with a K-wire before
between the anatomic axis of the metatarsal and
checking the position. If further correction is
the distal articular surface, it will not alter the
required, minimal resection of the inferolateral
DMMA. However, it may be of use when
aspect of the metatarsal base is performed.
combined with a distal osteotomy to correct a
The arthrodesis can be secured by means of
congruent deformity with increased IMA (a
screws or a custom plate. To use screws, a 3.5 mm
double osteotomy).
glide hole is drilled from the dorsum of the
metatarsal, starting 15–20 mm from the joint and
slightly laterally, aiming for the cuneiform. It is Consent and risks
important to avoid aiming too plantarwards,
which results in a poor hold on the cuneiform. • Malunion: any misorientation of the plane of the
The cuneiform is then drilled, using a 2.5 mm drill osteotomy can result in significant accidental
in standard AO fashion. Prior to inserting the misplacement of the metatarsal head
screw, an oval groove in the transverse plane • Overcorrection: given the power of this
should be created (using a small burr or osteotomy to realign the shaft, overcorrection
countersink) to accommodate the head of the and hallux varus can be troublesome, especially
screw and avoid breaking the dorsal cortical when combined with an aggressive lateral
bridge. Once tightened, a second screw can be release
inserted from the cuneiform to the metatarsal, in
a parallel sagittal plane to the first screw. Incision
A dorsal incision is made over the base of the
Closure metatarsal, avoiding any superficial cutaneous
The soft tissues are closed over the fusion prior to nerves.
skin closure.
Surgical technique
Specific postoperative instructions The osteotomy is ideally placed about 1 cm from
If satisfactory fixation is achieved and the patient the TMTJ in metaphyseal bone to provide a broad
is compliant, they may mobilize postoperatively area for union. A dome osteotomy or closing or
in a forefoot-offloading wedge shoe for 12 weeks. opening wedge osteotomies can be performed.
First MTP joint cheilectomy 241
The lateral closing wedge will tend to shorten the Barouk LS. Forefoot reconstruction. Paris: Springer-
metatarsal. There are various plates designed to fix Verlag, 2005.
the opening wedge osteotomies. Weil LS. Scarf osteotomy for correction of hallux
The coronal plane of the osteotomy is vital – it valgus. Historical perspective, surgical technique,
should be perpendicular to the plane of the and results. Foot Ankle Clin 2000;5:559–80.
metatarsal. If the blade is directed too medially,
the head will be elevated and if directed too
laterally it will be depressed. In the sagittal plane,
the blade should be positioned perpendicular to FIRST METATARSOPHALANGEAL JOINT
the sole then angled slightly proximally. Once cut, CHEILECTOMY
the osteotomy can provisionally be reduced and
the position checked. If satisfactory the osteotomy PREOPERATIVE PLANNING
is fixed with two screws or a screw and wire.
Hallux rigidus, or degenerative arthritis of the first
Keller procedure MTPJ, is a common condition. Although in its
early stages it can be managed with conservative
This involves excision of the medial prominence measures, such as footwear and activity
of the metatarsal and the proximal third of the modifications, patients often require operative
phalanx to relax the lateral structures and allow intervention. Cheilectomy, from the Greek for lip,
correction of the toe, which is then held with a cheilos, addresses both the pain and stiffness found
temporary K-wire. Although once commonly in this condition.
performed, its generally unsatisfactory results
have caused it to fall out of favour. The patient is Indications
left with a floppy great toe and, by defunctioning
• Mild to moderate degenerative changes in the
the hallux, is prone to overload their lesser rays
first MTPJ with pain and stiffness, failing to
with resultant pain. However, it can be considered
respond to conservative management
in the older, minimally ambulatory patient who
• More advanced degenerative changes in a
has footwear problems or in those patients whose
patient unwilling to lose joint movement
soft tissues or general fitness precludes a more
(patient must be counselled that there may be
aggressive procedure.
improvement in movement but only limited
GENERAL POSTOPERATIVE CARE AND improvement in pain)
INSTRUCTIONS • Prominent dorsal osteophytes causing footwear
problems.
• The foot is dressed with a standard forefoot
dressing, extending above the ankle.
Contraindications
• The foot is elevated for 72 hours to reduce Advanced degenerative changes with loss of joint
swelling. space.
• The patient may mobilize, fully weightbearing,
in a forefoot-offloading wedge shoe for 6 weeks.
• After skin wounds have healed, the patient is Consent and risks
taught passive mobilization of the MTPJ to
• Failure or recurrence of symptoms: especially if
reduce stiffness.
the degenerative changes are more extensive
than appreciated preoperatively or if insufficient
RECOMMENDED REFERENCES resection is performed
• Instability of first MTPJ: especially if resection
Barouk LS. Scarf osteotomy for hallux valgus
exceeds 35 per cent of joint surface
correction. Local anatomy, surgical technique, and
• Damage to dorsal cutaneous nerve and neuroma
combination with other forefoot procedures. Foot
formation
Ankle Clin 2000;5:525–58.
242 Surgery of the foot
SURGICAL TECHNIQUE
Landmarks
• The MTPJ of the great toe is easily palpable
Figure 14.8 First metatarsophalangeal joint cheilectomy
• Extensor hallucis longus (EHL) tendon. – minimum and maximum resection levels
Incision
A 5 cm dorsal incision is made along the medial 60°) is confirmed. Any prominent osteophytes are
border of EHL centred over the first MTPJ. removed from the dorsal phalanx and the medial
and lateral aspect of the head, and the joint is
Dissection irrigated to thoroughly wash out. Bone wax can
be used sparingly to reduce bleeding and
The underlying extensor hood is incised in line adhesions.
with the incision but leaving a cuff of tissue on the
medial side of the tendon to avoid violating the
tendon sheath and reducing the risk of adhesions.
Closure
The joint capsule is incised and the joint exposed Careful closure of the capsule with interrupted
by dissection medially and laterally. Alternatively, Vicryl precedes skin closure. A forefoot dressing is
a medial approach, as described in first MTPJ applied to above the ankle.
arthrodesis, may be used.
POSTOPERATIVE INSTRUCTIONS
PROCEDURE
The foot is elevated for 48 hours. The patient fully
A full synovectomy is performed and any loose weightbears on a postoperative shoe and
bodies removed. Flexing the joint fully allows aggressive active and passive mobilization begins
inspection of the joint surface. In mild and once skin healing has occurred
moderate disease, the damage is usually limited to
the dorsal aspect. Ideally, the resection should RECOMMENDED REFERENCE
extend from just dorsal of the edge of the viable
cartilage to just proximal of the dorsal Coughlin MJ, Shurnas PS. Hallux rigidus. Grading
prominence of the head. However, care should be and long-term results of operative treatment. J
taken to ensure that this resects 20–30 per cent of Bone Joint Surg Am 2003;85:2072–88.
the joint (Fig. 14.8).
Note on resection level (Fig. 14.8): a common
cause for failure of cheilectomy is insufficient
resection. A minimum of 20 per cent of the FIRST METATARSOPHALANGEAL JOINT
articular surface must be removed, even if this ARTHRODESIS
includes normal joint surface, to ensure adequate
movement. Exceeding 35 per cent is likely to PREOPERATIVE PLANNING
destabilize the joint.
The dorsal prominence is resected with a saw or Once a patient has developed severe hallux
osteotome and satisfactory dorsiflexion (ideally rigidus, a cheilectomy is unlikely to address the
First MTP joint arthrodesis 243
Too flexed
The joint is positioned as required and the forefoot until evidence of clinical and
provisionally held with a K-wire. The sagittal radiological union. If there is concern about the
position of the toe is then assessed with regard to compliance of the patient, a cast may be used.
a flat surface as outlined above. The coronal
position should be of sufficient valgus to avoid the RECOMMENDED REFERENCE
medial border of the toe rubbing upon the toe-
box of a shoe but not so much that there is Coughlin MJ, Shurnas PS. Hallux rigidus. J Bone
impingement of the hallux against the second toe; Joint Surg Am 2004;86(Suppl 1):119–30.
10–15° HVA is usually appropriate. There should
be no rotational deformity.
In primary surgery with good bone stock, the INGROWING TOENAIL SURGERY
arthrodesis can be secured with two crossed
screws. The first is inserted with a lag technique to PREOPERATIVE PLANNING
compress the joint; the second provides a
derotational function. Alternatively, a custom- A multitude of operations exist to deal with
made plate may be used. ingrowing toenails, or onychocryptosis. Chemical
ablation with phenol of either part or all of the
Closure nail matrix is associated with lower recurrence
rates than surgical ablation in most series.
• Careful closure of the capsule with interrupted
Vicryl precedes skin closure.
Indications
• A forefoot dressing is applied to above the Painful onychocryptosis or recurrent infections.
ankle.
Contraindications
POSTOPERATIVE INSTRUCTIONS
• Severe digital vascular compromise is an
The foot is elevated for 72 hours. A reliable absolute contraindication
patient can mobilize in a wedge shoe to offload • Active infection is a relative contraindication.
Ingrowing toenail surgery 245
Recurrence may be better treated with total All blood is carefully cleared from the field and
matrix ablation. all exposed skin protected with petroleum jelly. A
cotton bud is soaked in phenol and inserted along
the exposed nail bed, under the ungual fold, and
Consent and risks
left for 60 seconds. This process is repeated once
• Recurrence: less than 5 per cent more then the whole area irrigated with copious
• Infection: superficial infection commonly amounts of saline. The tourniquet is released and
dependent on postoperative care a toe dressing applied.
• Phenol burns: rare
POSTOPERATIVE CARE AND
INSTRUCTIONS
Anaesthesia and positioning
The foot is elevated for 48 hours then the dressings
Toenail surgery can be effectively performed under are reduced. The wound is then washed in tepid
digital block with or without additional sedation. boiled salted water twice a day using a baby
A bloodless field is established with the use of a toothbrush, sweeping in a proximal to distal
digital tourniquet secured with an artery forcep. direction. When showering the patient is instructed
to aim the spray directly over the wound.
SURGICAL TECHNIQUE
RECOMMENDED REFERENCE
The affected nail border is elevated from the nail
bed and surrounding skin by blunt dissection with Herold N, Houshian S, Riegels-Nielsen P. A
forceps. The nail border is then cut using a blade prospective comparison of wedge matrix resection
or scissors underneath the ungual fold (Fig. with nail matrix phenolization for the treatment
14.10). Grasping the fragment with an artery of ingrown toenail. J Foot Ankle Surg 2001;40:
forcep and using a rotating movement, the nail 390–5.
border is carefully avulsed in its entirety, complete
with the widened germinal base. The nail groove
is then carefully curetted.
INTERDIGITAL NEUROMA
PREOPERATIVE PLANNING
Indications
Proven, symptomatic interdigital (Morton’s)
neuroma in the third (80–90 per cent) or second
(10–20 per cent) web space failing to respond to
conservative treatment.
Nail
matrix Contraindications (relative)
• Vague symptoms or unusual location
• Other causes of metatarsalgia
• Lack of response to accurate injection of lesion.
• Scar pain (especially with plantar incision) Plantar pressure will usually deliver the neuroma
• Interdigital numbness: common but rarely into the wound. Sometimes it will be obscured by
troublesome a bursa which requires excision. Taking care to
• Vascular damage and digital ischaemia: risk if protect the common digital artery, the neuroma is
multiple web space explorations are undertaken retracted proximally and the two true digital
nerves are divided. The nerve is then traced as
proximally as possible and then divided under
Anaesthesia and positioning traction such that the cut end is proximal to the
weightbearing area of the foot. The specimen
May be performed under general or regional should be sent for histology for confirmation of
anaesthesia. The patient is positioned supine with the diagnosis.
an ankle or thigh tourniquet to provide a
bloodless field.
Closure
SURGICAL TECHNIQUE After release of the tourniquet, haemostasis is
obtained. Skin is closed in a single layer and a
Landmarks
forefoot bandage is applied.
The dorsal aspect of the affected web space.
POSTOPERATIVE CARE AND
Incision INSTRUCTIONS
A longitudinal incision is placed over the dorsum The patient should elevate the foot for 48 hours.
of the foot, starting in the web space and They may mobilize, weightbearing as tolerated, in
extending 3–4 cm proximally. (An insufficient a postoperative flat shoe.
incision is commonly found in recurrent cases and
is to be avoided.) RECOMMENDED REFERENCE
• Mallet toe – a flexion deformity of the distal IPJ Anaesthesia and positioning
(DIPJ), often resulting in a callosity on the tip
of the toe. Anaesthesia can be regional or general. If surgery
• Hammer toe – a flexion deformity of the is limited to the interphalangeal joints a digital
proximal IPJ (PIPJ), often associated with block can be used. A supine position is used, with
hyperextension of the DIPJ and an the foot at the end of the table.
accommodative hyperextension of the MTPJ.
• Claw toe – a term usually reserved for multiple
toes and often associated with an underlying
SURGICAL TECHNIQUES
neurological condition. The primary deformity
is one of hyperextension of the MTPJ with
Percutaneous flexor digitorum longus
secondary flexion of the PIPJ.
tenotomy
Indications Indication
Flexible mallet deformity
• Painful lesser toe deformity not responding to
conservative treatment Incision
• Severe lesser toe deformity causing footwear
Holding the toe to put the flexor tendon under
problems and not responding to footwear
tension, a size 15 blade (or tenotomy blade if
modification.
available) is used to make a 2–3 mm incision over
the DIPJ flexor crease.
Contraindications
Procedure
• Vascular insufficiency
• Local infection Structure at risk
• Undiagnosed underlying neurological condition
(relative). • Neurovascular bundles
Consent and risks With the blade facing away from the
neurovascular bundle, the tightened tendon is
• Infection: <1 per cent palpated with the blade and divided. The toe is
• Neurovascular damage: <1 per cent then released to check the degree of correction.
• Vascular insufficiency of the digit following
correction of a severe or long-standing
Closure
deformity: may require further shortening or
accepting a slightly flexed position Formal closure of the wound is not required.
• Recurrence of deformity
• Swelling DIPJ arthrodesis
• Non-union of arthrodesis: 20–50 per cent of PIPJ
arthrodeses in some series formed a fibrous Indication
union, but this does not correlate with
Fixed mallet deformity
postoperative dissatisfaction
• Malunion of arthrodesis: hyperextension of the
joint or varus/valgus deformity often poorly
Incision
tolerated An elliptical incision is made over the DIPJ and
• Loss of movement or function of the toe, carried down to bone, excising the extensor
depending on procedure performed tendon. Care is taken to avoid damage to the nail
matrix distally.
248 Surgery of the foot
Procedure
Facing the blade away from the neurovascular
bundles, the collateral ligaments are divided,
Structure at risk allowing deliverance of the condyles of the
• Neurovascular bundles proximal phalanx into the wound. Using a bone
cutter, the condyles are excised at the
Lesser metatarsal (Weil’s) osteotomy 249
metaphyseal flair. Sufficient bone must be progressive capsular and collateral releases are
removed to allow the toe to be straightened performed both medially and laterally. In long-
without undue tension on the tissues, especially standing deformities, adhesions may exist between
the neurovascular bundles. The plantar plate is the plantar capsule and the metatarsal head which
released from the middle phalanx allowing its should be released. Once satisfactory release is
base to be delivered. The articular surface is then achieved, the EDL should be repaired with
decorticated using a nibbler. A double ended K- absorbable suture and the wound closed. If, despite
wire is advanced in an antegrade direction through maximal release of the MTPJ, the joint cannot be
the middle and distal phalanges, aiming to come reduced, a metatarsal osteotomy should be
out just below the nail bed. The joint is then considered. (see ‘Lesser metatarsal [Weil’s]
reduced and the wire advanced into the proximal osteotomy’, below).
phalanx to secure the joint.
POSTOPERATIVE CARE AND
Closure INSTRUCTIONS
The wound is closed with a non-absorbable After all lesser toe surgery the tourniquet should
mattress sutures to secure skin and extensor be released prior to waking the patient and the toe
tendon en masse. If the MTPJ remains extended, a observed. If reperfusion is slow, releasing
dorsal release (see below) should be included to excessively tight dressings and hanging the foot
avoid a ‘cock-up’ deformity. over the side of the table usually allows the toe to
reperfuse. If the toe remains white and a K-wire
MTPJ release has been inserted, gently bending the arthrodesed
joint will relieve excess tension on the blood
Indication vessels.
Hyperextension of the MTPJ with or without All patients can fully weightbear on a flat
subluxation. postoperative shoe. K-wires, if used, should be
removed at 4–6 weeks.
Incision
RECOMMENDED REFERENCE
Structures at risk Coughlin MJ. Lesser-toe abnormalities. J Bone
• Dorsal veins Joint Surg Am 2002;84:1446–69.
• Dorsal sensory nerve branches
LESSER METATARSAL (WEIL’S)
A 3 cm incision is made in line with the OSTEOTOMY
metatarsal, centred over the MTPJ. If two adjacent
joints are being addressed, the incision should be PREOPERATIVE PLANNING
made in the web space. Attempt should be made
to protect the dorsal veins and sensory nerves. Historically, the Helal osteotomy was a popular
treatment for lesser metatarsal overload and
Procedure subluxed lesser MTPJs. This has largely been
Release of the joint should occur in a stepwise replaced by the Weil osteotomy, as popularized by
manner and stop when satisfactory release Barouk.
achieved. The extensor digitorum longus (EDL)
and extensor digitorum brevis (EDB) to the toe Indications
(EDL lies medial to EDB) are identified and their
tightness assessed. If tight, the EDB may be • Overload of a metatarsal head secondary to a
divided but the EDL should be z-lengthened. A relatively long metatarsal
dorsal capsulotomy is performed then, with the • Reduction of a chronically subluxed or
blade facing away from the neurovascular bundles, dislocated MTPJ.
250 Surgery of the foot
Contraindications
• Gross deformity of the joint
• Vascular insufficiency or infection.
• Failure of footwear adaptations and other should follow the line of tension along the
conservative measures extensor tendon. The plantar limb should be
longer and heading laterally (Fig. 14.12). The skin
Contraindications is incised with care and the neurovascular bundles
identified and protected.
Digital ischaemia or poor perfusion.
Procedure
Consent and risks
The tight extensor tendons are divided then the
• Neurovascular damage and risk of toe ischaemia: joint capsule exposed. The tight dorsal capsule
reduced be careful dissection and avoidance of and usually the collateral ligaments require
traction or manipulation of the toe release. Sometimes the plantar capsule is adherent
• Recurrence of deformity: rare and needs to be dissected off. The toe should now
assume the required position.
Contraindications
HINDFOOT ARTHRODESIS
• Active infection or ischaemia of the limb is an
PREOPERATIVE PLANNING absolute contraindication.
• A more proximal uncorrected deformity is a
The three joints of the hindfoot, the subtalar (ST), relative contraindication. It is difficult to judge
calcaneocuboid (CC) and talonavicular (TN) hindfoot alignment if there is a more proximal
joints, can be arthrodesed individually or in deformity. Furthermore, if a proximal deformity
combination, depending upon the indication. is subsequently corrected, the hindfoot
However, as all three joints work in unison, fusion alignment may be rendered incorrect. It is
of one will affect the others. As the normal therefore prudent to address proximal
hindfoot swings into varus during gait, Chopart’s deformities first.
joints (TN and CC) are locked in position to • Ipsilateral ankle fusion is a relative
provide a firm platform. Therefore, a subtalar contraindication – the patient must be
fusion must avoid varus to leave Chopart’s joints counselled that a combined ankle and hindfoot
relatively mobile and avoid fixed supination of the fusion will result in a loss of normal gait and
foot. Similarly, fusion of the TN joint in isolation possibly the need for footwear adaptations to
fixes the CC joint and greatly reduces the walk.
movement of the ST joint. Therefore, in
arthrodesing one or more of these joints, attention
to the position of all three must be taken. Consent and risks
The ultimate aim of any hindfoot fusion is to
provide a pain-free, stable hindfoot and a foot (See also ‘Principles of foot and ankle arthrodesis’,
that can be placed flat on the floor for weight- p. 230.)
bearing. • Non-union: the TN joint is especially prone to
non-union. This is likely to be due to its curved
surface and extensively cortical composition
Indications making adequate visualization and preparation
technically difficult. Obtaining adequate rigid
(See also ‘Principles of foot and ankle arthrodesis’, fixation can also be difficult compared with the
p. 230.) ST joint
• Painful arthropathy of one or more hindfoot • Malunion: due to incorrect positioning or
joints secondary to degenerative, inflammatory fixation failure. A malunion preventing the
or traumatic causes not responding to patient from placing the foot flat on the floor,
conservative management. In such cases often with overload of the lateral border, is very
isolated fusion of the affected joint can be poorly tolerated by the patient and often
considered. requires revision
• Fixed deformity of the hindfoot not amenable
to soft tissue correction and/or osteotomy.
Historically, this was primarily for paralytic
conditions, especially poliomyelitis. Hindfoot Anaesthesia and positioning
fusions are now more commonly performed for
tibialis posterior dysfunction, rheumatoid (See also ‘Principles of foot and ankle arthrodesis’,
arthritis and congenital neuromuscular p. 231.)
disorders. In such cases a double fusion of the For isolated subtalar fusion a lateral decubitus
TN and CC joints, or a triple fusion of all three position, with the operative side up, allows
joints is indicated. excellent access and visualization. For TN or
• Gross instability of the hindfoot with bony double/triple arthrodeses, a supine position is
destruction, as seen in rheumatoid arthritis or optimal. The use of a bolster under the calf allows
Charcot’s joints in people with diabetes. free access around the foot.
Hindfoot arthrodesis 253
Sural Extensor
hallucis longus
Superficial
peroneal
Tibialis B
posterior Tibialis
A anterior
Figure 14.13 (a) Approaches for hindfoot arthrodesis – utility lateral approach. (b) Approaches for hindfoot
arthrodesis – anterior (A) and anteromedial (B) approach to talonavicular joint
254 Surgery of the foot
Incision
Contraindications
• Active infection or critical ischaemia of the Structure at risk
limb is an absolute contraindication.
• A more proximal uncorrected deformity is a • Sural nerve
relative contraindication. It is difficult to judge
hindfoot alignment if there is a more proximal
deformity. Furthermore, if a proximal deformity Some authors advocate an oblique lateral incision
is subsequently corrected, the hindfoot over the line of the proposed osteotomy.
alignment may become incorrect. It is therefore Unfortunately, this coincides with the course of
advisable to address proximal deformities first. the sural nerve and puts it at risk. We therefore
advise an extensile lateral incision, commonly
used for calcaneal fixation, as the sural nerve is
Consent and risks protected in the elevated flap. This also allows
better visualization of the calcaneum. The inferior
• Neurovascular damage: the sural nerve is in the limb of the incision runs along the junction of the
zone of the incision and must be avoided. On the plantar and dorsal skin. The superior limb extends
medial extent of any osteotomy, the superiorly in line with the anterior border of the
neurovascular bundle is close by and can be tendo-Achilles (Fig. 14.14). The extent of the
injured with aggressive use of power tools exposure required is less than for calcaneal
• Malunion: usually due to technical errors in fixation but the insertion of tendo-Achilles
judging the degree of correction but also due to superiorly and plantar fascia inferiorly should be
hardware failure visualized.
• Non-union: rare due to large surface area of
cancellous bone Dissection
• Recurrence of deformity, especially if the
The incision is carried straight down to bone and
deforming soft tissues are not correctly balanced
the flap elevated in the subperiosteal layer with
or there is a progressive neuromuscular condition
minimal trauma to the soft tissues.
256 Surgery of the foot
Viva questions
1. Describe how you can maximize the union rate 11. Describe the mechanics of a Girdlestone
for a midfoot arthrodesis. tendon transfer for the lesser toes and when
you would perform this.
2. In the context of hallux valgus deformity, what
is congruency and how does it affect your 12. How do you assess the severity of hallux
decision-making process? rigidus and how does this influence your
treatment options?
3. What radiographs do you use to assess hallux
valgus deformity, what angles do you measure 13. What is the optimum position of arthrodesis of
and how does this influence your choice of the first metatarsophalangeal joint (MTPJ) and
operation? how would you assess this intraoperatively?
4. What surgical approach do you use for a first 14. Describe the anatomy of a toenail. How does
metatarsal osteotomy and what are the this knowledge help in the treatment of
important structures at risk? ingrowing nails?
5. Describe the blood supply to the first 15. What is a Morton’s Neuroma and where is it
metatarsal head. How can your choice of hallux most commonly found?
valgus procedure affect the blood supply?
16. How does movement of the subtalar joint in
6. What structures do you need to identify in gait affect movement of the Chopart joints
performing a lateral release in a hallux valgus (talonavicular and calcaneocuboid)?
deformity?
17. Describe your understanding of the concept of
7. In a scarf osteotomy, what is ‘troughing’ and ‘Talar neutral’ and why is this useful in
how does the design of your osteotomy assessing foot position?
influence occurrence?
18. What surgical approach do you use to reach
8. Why is a Keller’s procedure generally poorly the subtalar joint, what are the landmarks and
tolerated by patients and when would you what structures are at risk?
consider performing one?
19. What structures are at risk during a calcaneal
9. What are the key differences between a Weil’s osteotomy?
and a Helal’s osteotomy of the lesser
20. When would you consider performing a
metatarsals?
lateralizing calcaneal osteotomy?
10. What is the difference between a claw toe,
mallet toe and a hammer toe?
15
Limb reconstruction
Robert Jennings and Peter Calder
BIOMECHANICS
PRINCIPLES OF LIMB
RECONSTRUCTION • Monolateral rail:
– Cantilever loading
When subjected to slow, steady traction, under – Concentrated high stress on near cortex
the appropriate conditions, living tissue becomes • Circular frame:
metabolically activated and is able to regenerate. – Beam loading
This ‘tension-stress’ effect was described by – More even distribution of stress across
Professor Gavril Abramovich Ilizarov from Kurgan cortices.
in western Siberia, who pioneered the field of
limb reconstruction from the early 1950s and Use of all-wire fixation across a diaphysis is less
developed the highly successful techniques that attractive, due to risks to soft tissues. Hence, hybrid
are still in use today. fixation with half-pins and wires is preferred.
Callus, formed at a corticotomy site, can be
distracted at speeds of up to 1 mm per day and,
reliably, form new bone in the process of METHODS TO IMPROVE STABILITY
‘distraction osteogenesis’. Once the goal length is
• Wire:
achieved, a period of consolidation is required
– Increase diameter (1.8 mm for adult, 1.5 mm
before fixator removal. This takes approximately
for child)
30–40 days per centimetre of lengthening to
– Increase tension (130 Nm for adult, 110 Nm
prevent bowing or fracture. Anecdotally, the
for child)
maximum, safe distraction possible per procedure
– Increase crossing angles (Fig. 15.1)
is 20 per cent of the original length of the bone
being lengthened.
Distraction osteogenesis requires:
• Stability
• Maintenance of blood supply
• A latency period (5–7 days)
• Appropriate rate of distraction (0.75–1 mm per 90° 45°
day)
• Appropriate rhythm (frequency) of distraction
(0.25 mm, 6–8 hourly).
SURGICAL TECHNIQUE
Distal anatomical
and mechanical axis Wire insertion
• Aseptic ‘no hands’/‘Russian’ technique
• Alcohol-soaked gauze used to coat and hold wire
• Low heat generation is ensured via short,
intermittent bursts with the wire driver
Figure 15.3 ‘CORA’ (centre of rotation of angulation) – • Wire tapped with mallet, when through
mechanical and anatomical axis contralateral skin.
Femoral lengthening 261
Wire/Half-pin placement
• ‘Safe corridors’ – avoid neurovascular structures
• Avoid crossing compartments, if possible
• Soft tissues on stretch, e.g. quadriceps in
flexion, hamstrings in extension (helps
postoperative mobility).
Corticotomy
• Low energy
• Minimal incision, to admit osteotome
• Periosteum incised and preserved, when
possible
• A row of holes are pre-drilled with a 4.8 mm
(a) (b)
drill, with saline used for cooling. This
technique allows low heat generation, reducing
corticotomy site bone necrosis
• An osteotome is used to join holes, with a twist
Figure 15.5 With the hinge placed along the ‘bisector
line of the CORA’, there will be no translation
to break the posterior cortex.
Note: latent period: 5–7 days; quarter turns: 3–4
Half-pin insertion times per day (0.75–1 mm/day).
Figure 15.6 With the hinge placed off the ‘bisector line of the CORA’, translation will result
262 Limb reconstruction
SURGICAL TECHNIQUE
Corticotomy
Landmarks
Junction of the proximal metaphysis and
diaphysis – 1.5 cm distal to lesser trochanter.
available for both femur and tibia. Elongation of • Periosteum incised, then lifted off medially and
the internal mechanism is achieved by alternating laterally with blunt dissection
rotation of the limb and measured with a hand- • Corticotomy technique as above.
held monitor.
Procedure
• Two rings per bone segment (near and far)
TIBIAL LENGTHENING (FIG 15.9) • Two wires/half-pins per ring
• Four connecting, threaded rods between rings
PREOPERATIVE PLANNING (Fig. 15.10)
• Fibular osteotomy
See ‘Principles of limb reconstruction’ (p. 258). – Mid-diaphyseal avoids neurovascular struc-
tures
SURGICAL TECHNIQUE • Fix fibula (proximal and distal), to avoid joint
subluxation.
Corticotomy
Landmarks
Junction of the proximal metaphysis and
diaphysis, c.1.5 cm distal to tibial tuberosity.
PRINCIPLES OF DEFORMITY
CORRECTION
PREOPERATIVE PLANNING
Operative planning
The initial decision is between acute and gradual
Figure 15.9 Tibial Ilizarov frame for lengthening correction of the deformity:
264 Limb reconstruction
• Acute
– Mild deformity
– Opening or closing wedge
– Plate and screws
– Intra-medullary (IM) nail
– External fixation
• Gradual
– More severe deformity
– Less risk of neurological damage
– Potential for revision of correction protocol
– Distraction osteogenesis
– Circular frame e.g. Ilizarov or hexapod type
(e.g. Taylor Spatial Frame) Figure 15.12 Radiograph of a simple Ilizarov frame
construct used to correct deformity in a congenitally
– Monolateral fixator: on convex side –
short tibia
distraction at osteotomy site (See Fig. 15.5
page 261); on concave side – compression at
osteotomy site therefore requires wedge
excision.
SURGICAL TECHNIQUE
Example: Simple, tibial diaphyseal deformity
correction with a circular frame.
• Application of proximal and distal rings (see
above; Fig. 15.11)
• Osteotomy at CORA (see above)
• Ilizarov method
– Inter-ring connections with hinges along
bisector line of CORA (Fig. 15.12).
• Taylor Spatial Frame (TSF) method (Figs 15.13
and 15.14)
– Inter-ring connections with six oblique,
adjustable struts (‘virtual hinge’) Figure 15.13 Tibial Taylor Spatial Frame
RECOMMENDED REFERENCES
Viva questions
1. What are the causes of leg length discrepancy? 8. What are the problems associated with shoe
raises?
2. What problems are associated with leg length
discrepancy? 9. What problems may occur as a consequence of
acute shortening procedures?
3. How do you assess length discrepancy of the
lower limbs? 10. Who was Professor Gavril Abramovich Ilizarov?
4. What are the differences between true, 11. What problems may occur due to leg
apparent and functional leg length lengthening procedure?
discrepancy? 12. What are the prerequisite factors necessary for
5. What are the treatment options for leg length successful leg lengthening?
discrepancy in both adults and children? 13. What are the reasons for leaving a ‘latency
6. What are the relative percentage contributions period’ prior to commencing distraction?
to normal growth of all of the lower limb 14. What are the advantages and disadvantages of
physes? lengthening intra-medullary nails?
7. How can you predict the magnitude of leg 15. Give the causes of lower limb deformity.
length discrepancy at skeletal maturity?
266 Limb reconstruction
16. How do you assess the degree of lower limb 19. What are the consequences of hinge
deformity? misplacement when applying an Ilizarov frame
for deformity correction?
17. Draw a ‘Selenius graph’.
20. What are the advantages of using a ‘Taylor
18. What options are available for correcting lower
Spatial Frame’ rather than an Ilizarov frame for
limb deformity in both adults and children?
deformity correction?
16
Paediatric orthopaedic surgery
Russell Hawkins and Aresh Hashemi-Nejad
SURGICAL TECHNIQUE
Figure 16.1 The trajectory of the drill should be
checked periodically using the image intensifier to
Landmarks ensure obliteration of the physis
The image intensifier is used to mark the
orientation of the physis in the frontal plane and
the midpoint of the physis in the lateral plane. shaped area of physeal cartilage (Fig. 16.2). This
technique is then repeated on the medial side. The
Approach swarf should be inspected to ensure removal of
physeal cartilage. Further curettage of the
A 1–2 cm longitudinal incision is centred over the epiphyseal surface is performed to remove any
midpoint of physis medially and laterally. A larger remaining physeal cartilage.
incision is made laterally to identify and protect
the common peroneal nerve if performing Closure
proximal fibular epiphysiodesis.
Layered closure using absorbable subcuticular
Dissection material to skin.
Femoral neurovascular
bundle
Sartorius
Profunda
femoris
Medial
femoris
circumflex
vessels
Pectineus
Adductor longus
Gracilis Figure 16.4 Child plastered in the ‘human position’
POSTOPERATIVE INSTRUCTIONS
Procedure
• Plaster check prior to discharge.
A 22G spinal needle is introduced beneath the • Limited slice CT at 2/52 to confirm
palpable adductor longus tendon in the groin and maintenance of reduction.
advanced cranially towards the ipsilateral scapular • Convert to abduction brace at 10/52.
until the tip is felt to traverse the hip capsule. The • Wean out of brace after further 6/52.
position is confirmed with image intensifier before Depending on acetabular development, night
instilling 0.5 mL of diluted contrast. time bracing may continue for up to 1 year.
DDH – open reduction 271
Indications Incision
• Children 6–18 months with: obstruction to A 2.5 cm, vertical skin crease incision is centred on
closed reduction (psoas tendon, contracted the palpable tendon of adductor longus.
capsule, ligamentum teres, transverse acetabular
ligament, and inverted limbus), an unstable safe Superficial dissection
zone, previous failed closed or open reduction
• Children presenting over 18 months.
Structures at risk
Contraindications • Anterior and posterior divisions of obturator
nerve
Children less than 6 months old.
272 Paediatric orthopaedic surgery
The fascia overlying the tendons of adductor second line is then dropped vertically downwards
longus and gracilis is opened along their length from the ASIS. Next, a 5 cm bikini line incision is
and fractional lengthening tenotomies are marked 2 cm inferior and parallel to the inguinal
performed. Adductor magnus and brevis are ligament, one-third of it medial and two-thirds
exposed with blunt dissection. Branches of the lateral to the vertical line.
obturator nerve are identified on the superficial
surface of the adductor brevis and are protected. Superficial dissection
• Medial circumflex femoral artery The interval between sartorius and tensor fascia
lata is developed to reach the rectus femoris and
The plane between the adductor magnus and gluteus medius.
brevis is dissected to access the lesser trochanter.
A psoas tenotomy is performed under direct Deep dissection
vision avoiding the medial femoral circumflex
vessels which pass over the medial surface of the The interval between the rectus femoris and
psoas tendon distally. gluteus medius is dissected and the straight head
A medial arthrotomy is made above the vessels of the rectus femoris is detached from the anterior
and the acetabular attachment of the ligamentum capsule. It may then be retracted medially to allow
teres is divided and used as a traction aid to psoas tenotomy and L-shaped anterior arthrotomy
relocate the femoral head. It is then sutured to the (see Figure 16.5).
anterior inferior capsule.
PROCEDURE
ANTERIOR APPROACH Obstructions to reduction are removed as
necessary; pulvinar is extracted, the transverse
Landmarks ligament is released and the ligamentum teres
• Anterior superior iliac spine (ASIS) excised if obstructive. Adductor releases are
• Pubic tubercle. performed, via a separate groin incision, to
facilitate reduction as required.
Incision The redundant capsule is tightened with
capsulorrhaphy following reduction. Using the
The line of the inguinal ligament is marked image intensifier, the position of maximum
between the ASIS and the pubic tubercle. A stability is identified; the hip is placed in 30° of
Gluteus medius
Rectus femoris (cut)
Tensor fascia
Sartorius
lata
Anterior hip capsule Figure 16.5 Anterior approach to the right hip
DDH – pelvic osteotomy 273
internal rotation, flexion and abduction then each developmental dysplasia of the hip. A long term
of these positions is removed in sequence to review. J Bone Joint Surg Br 2000;82:17–27.
determine positioning in plaster and the need for
future surgery.
Femoral osteotomy or an acetabular procedure DEVELOPMENTAL DYSPLASIA OF THE
may be undertaken concomitantly if severe HIP – PELVIC OSTEOTOMY
dysplasia is present in an older child.
Operative planning inferior iliac spine (AIIS) using a Gigli saw. This
Congruency confirmed with EUA arthrogram. should appear to be parallel to the acetabular
surface on AP images. Hinging on the symphysis
Anaesthesia and positioning pubis, the acetabulum is rotated anteriorly and
General anaesthesia is used, together with laterally to gain coverage while avoiding
intravenous antibiotics. The patient is positioned retroversion.
supine with an ipsilateral sandbag in a position A wedge of bone from the iliac wing is inserted
suitable for image intensifier access. perpendicular to the weightbearing axis. The
‘winking sign’ should be noted on an image
intensifier (foreshortening of ipsilateral obturator
Surgical technique
foramen) and the position held with two threaded
Anterosuperior coverage is achieved at the expense Schantz pins across the osteotomy. Image
of posterior coverage by flexing the acetabular guidance is used to advance the pins
fragment. Typically, the lateral centre edge angle proximodistally beginning just proximal to the
will increase by 10°. It is performed via an anterior ASIS and aiming for the triradiate cartilage (Figs
approach (see ‘Developmental dysplasia of the hip 16.6 and 16.7).
– open reduction’, p. 272) extending the bikini
incision proximally over the iliac crest to allow
splitting of the iliac apophysis and subperiosteal
exposure of the ilium to reach the sciatic notch.
Procedure
Structures at risk
• Sciatic nerve – Rang retractors are placed in the
sciatic notch keeping them closely applied to
bone to protect the nerve
• Devascularization/denervation of abductors
An osteotomy is performed between the sciatic Figure 16.7 Radiograph showing left Salter osteotomy
notch and midway between the ASIS and anterior and ‘winking sign’
Procedure
PEMBERTON OSTEOTOMY The osteotomy is made 10–15 mm superior to the
AIIS passing a curved osteotome posteriorly to
Preoperative planning reach the ilioischial and iliopubic limb of the
triradiate cartilage (midway between sciatic notch
Indications
and posterior acetabular rim). The acetabulum is
• Double diameter dysplastic acetabulum hinged on the triradiate to improve coverage.
• Congruent hip Corticocancellous graft is harvested from the iliac
• Open triradiate cartilage wing and inserted into the osteotomy site.
• Close to normal range of motion Posterior stability negates the need for internal
• No degeneration fixation.
• Normal proximal femoral morphology
• Paralytic hip disorders/Ehlers–Danlos syndrome Closure
(posterior coverage is maintained, conferring As per Salter osteotomy.
stability).
dislocation of the hip. J Bone Joint Surg Am • Neurovascular damage: 1 per cent
1965;47:65–86. • Infection: <1 per cent
Salter RB. Innominate osteotomy in the treatment • Delayed/non-union: 1–5 per cent (greater risk
of congenital dislocation and subluxation of the with increasing age)
hip. J Bone Joint Surg Br 1961;43:518–39. • Failure of hardware: <1 per cent
Thomas SR, Wedge JH, Salter RB. Outcome at • Incomplete correction
forty five years after open reduction and • LLD: inevitable with closing wedge varus
innominate osteotomy for late presenting osteotomy
developmental dysplasia of the hip. J Bone Joint • Joint degeneration
Surg Am 2007;89:2341–50. • Further surgery (removal of hardware, complex
arthroplasty)
Indications
Anaesthesia and positioning
• Persistent dysplasia following DDH (coxa
• General anaesthesia
valga, anteversion)
• Supine with ipsilateral buttock sandbag
• Congruent reduction in abduction and internal
• Intravenous antibiotic prophylaxis
rotation
• Image intensifier.
• Reasonable sphericity (lateral portion of head
intact).
Contraindications
• Advanced avascular necrosis
• Active infection.
PROCEDURE
A guidewire is passed under image intensifier
control to avoid malposition and joint penetration.
After measuring and over-drilling the wire, a
partially threaded 6.5–7.5 mm diameter cannulated
screw is inserted. A reverse cutting thread is used
for easier subsequent removal. Despite an increase
in shear strength across the physis using multiple
screws, the use of a single screw diminishes the risk
of chondrolysis and avoids the disproportionate
complication rate of multiple screws.
The passage of guidewire, drill and screw
should be performed under image guidance to
avoid joint penetration. The screw tip should
reach the centre of the epiphysis, 5 mm from the
articular surface with a minimum of three to four
threads crossing the physis to provide adequate
fixation. At completion, live screening of the hip is
performed to ensure solid fixation of the epiphysis
and confirm screw position.
Figure 16.11 Illustration of Billings lateral radiograph
showing slip Closure
Subcuticular absorbable material is used to close
the stab incision.
Loder RT, Richards BS, Shapiro PS, et al. Acute • Slip progression
slipped capital femoral epiphysis. The importance • LLD: 1–2 cm shortening
of physeal stability. J Bone Joint Surg Am • Further surgery (removal of hardware/complex
1993;75:1134–40. arthroplasty)
Phillips SA, Griffiths WEG, Clarke NMP. The
timing and reduction of the acute unstable slipped
upper femoral epiphysis. J Bone Joint Surg Br Preoperative preparation
2001;83:1046–9.
Preoperative AP and lateral radiographs are used
to confirm the degree of slip and plan orientation
SLIPPED UPPER FEMORAL EPIPHYSIS of the osteotomy. Slings and springs are used
– OSTEOTOMY preoperatively for three weeks if acute or acute on
chronic.
carefully removed with a spoon from the the treatment of severe slipped capital femoral
posterior capsule. epiphysis after skeletal maturity. J Bone Joint Surg
Br 2006;88:1379–84.
Shortening the neck, removing the beak and Dunn DM, Angel JC. Replacement of the femoral
elevating the posterior capsule allows tension-free head by open operation in severe adolescent
reduction of the epiphysis. The epiphysis is slipping of the upper femoral epiphysis. J Bone
reduced onto the neck by placing the leg in Joint Surg Br 1978;60:394–403.
flexion, abduction and internal rotation. If Fish JB. Cuneiform osteotomy of the femoral neck
insufficient bone has been removed, the epiphysis in the treatment of slipped capital femoral
will not reduce easily and posterior structures will epiphysis. J Bone Joint Surg Am 1984;66:1153–68.
be placed under tension increasing the risk of Loder RT. Unstable slipped capital femoral
avascular necrosis. Shortening and wedging of the epiphysis. J Pediatr Orthop 2001;21:694–9.
neck should cause the epiphysis to overlap the
neck anteriorly giving a mushroom appearance.
Restoration of the Shenton line and a valgus TENDO-ACHILLES LENGTHENING
head–neck angle of 20° should be ensured using
the image intensifier.
While an assistant maintains position, a lateral
PREOPERATIVE PLANNING
stab incision is made according to the predicted
Various methods for tendo-Achilles lengthening
trajectory of cannulated screw followed by blunt
(TAL) exist and may be used in conjunction with
dissection down to the lateral cortex of the
other procedures. Percutaneous methods such as
proximal femur. A guidewire is then advanced
the Hoke and DAMP (distal anterior, medial
across the osteotomy to hold the epiphysis. Images
proximal, also called a White slide) technique and
are checked in two planes to confirm a satisfactory
open methods such as the Baker and Vulpius
position before definitive screw insertion. Similar
techniques are described (Figs 16.12–16.14). The
to pinning in situ, the entry point should not be
choice depends on the cause, the individual
below the lesser trochanter and screw tips should
patient and the surgeon’s preference.
be 5 mm short of the articular surface.
Dynamic screening allows confirmation of both
a solid fixation and satisfactory positioning of
hardware.
Closure
• Layered closure including capsular repair with
absorbable material
• Subcuticular absorbable material to skin.
POSTOPERATIVE INSTRUCTIONS
• Bed rest with slings and springs for 5 days.
• Mobilize 15 kg weightbearing 8 weeks. Increase
weightbearing status at 8 weeks, after
confirming union clinically and radiographic-
ally.
RECOMMENDED REFERENCES
Biring GS, Hashemi-Nejad A, Catterall A.
Outcomes of subcapital cuneiform osteotomy for Figure 16.12 Hoke percutaneous tenotomy
282 Paediatric orthopaedic surgery
conjoined tendon owing to controlled lengthening Borton DC, Walker K, Pirpiris M, et al. Isolated
and inherent stability. calf lengthening in cerebral palsy. J Bone Joint Surg
The medial and lateral thirds of the aponeurosis Br 2001;83:364–70.
are incised transversely 12 cm above the calcaneal Graham HK, Fixsen JA. Lengthening of the
insertion. A similar incision is then performed across calcaneal tendon in spastic hemiplegia by the
the middle third at least 3 cm proximally to allow white slide technique. J Bone Joint Surg Br
side to side contact after lengthening. A tongue and 1988;70:472–5.
groove pattern is created by joining the proximal
and distal cuts with two longitudinal incisions (see
Fig. 16.14, p. 282). Dorsiflexion of the ankle allows CONGENITAL TALIPES EQUINOVARUS
slide-lengthening of the aponeurosis and reveals any CORRECTION
remaining fibres which require incision.
The underlying muscle fibres of soleus are PONSETI TECHNIQUE
revealed as the aponeurosis is lengthened. Further
lengthening should not be performed once 10° of Preoperative planning
dorsiflexion is achieved on the table, and 3/0
absorbable sutures are placed across the Indications
longitudinal portions of the aponeurosis. Flexible CTEV.
RECOMMENDED REFERENCES
Operative planning
Baker LD. Surgical needs of the cerebral palsy The deformity can be graded using various
patient. J Bone Joint Surg Am 1956;38:313–23. methods. Dimeglio suggests a 20-point scoring
Congenital talipes equinovarus correction 285
system with four grades of severity which associated internal tibial torsion if present.
correlates with an increasing resistance to Midfoot pronation must again be avoided to
correction. The Pirani score helps to predict the prevent cavus deformity and a midfoot breach.
need for Achilles tenotomy and is based upon the • Equinus: With the hindfoot varus corrected,
severity of deformity in the midfoot and hindfoot serial casts are applied in a progressively
with a total maximum score of 6. Eighty-five per dorsiflexed position. This usually requires two to
cent of patients with scores over 5 will require three casts to achieve 15° of dorsiflexion and
tenotomy. 60° of external rotation. Dorsiflexion is achieved
via pressure beneath the midfoot rather than the
Anaesthesia and positioning metatarsals to avoid rocker-bottom feet.
No anaesthesia or sedation required unless the
patient is extremely uncooperative. An assistant is Additional procedures
essential.
Tendo-Achilles lengthening: If dorsiflexion of 15°
is not achieved, then a percutaneous tenotomy
Surgical technique under local anaesthesia is indicated. This is
preferable to posterior ankle and subtalar
Casting is performed weekly, correcting all three
capsulotomy as contraction of scar tissue in
components of the deformity in a predetermined
this region will lead to progressive loss of
sequence prior to additional operative procedures.
dorsiflexion.
At least three toe to groin casts are required over
Lateral transfer of the tibialis anterior tendon to
a period of 7–10 weeks depending on the severity
the lateral cuneiform may be required for
of deformity.
persistent supination.
Castings
• Cavus: caused by a relative pronation of the Postoperative care and instructions
forefoot due to a plantar flexed first ray. The
The final cast is left in situ for three weeks then
first ray is elevated with pressure beneath the
assessment made for residual equinus; 90 per cent
first metatarsal head to supinate the forefoot
of patients will require Achilles tenotomy.
and align it with the varus hindfoot. Forced
Denis Browne boots are worn fulltime for 2–3
pronation of the foot is avoided as this will
months then at night only for 2–4 years or until
worsen the cavus.
age 7. These maintain 15° of dorsiflexion (to avoid
• Varus and adductus: Correction of the
equinus) and 60° external rotation (to prevent
abnormally internally rotated calcaneus is
varus, adductus and in-toeing). High-top shoes are
achieved by external rotation using the lateral
worn during the day to maintain position.
talar head as the fulcrum. The cuboid and
Periodic evaluation should be performed by an
anterior calcaneus are displaced laterally by
experienced clinician to assess the relationship
applying medial pressure to the navicular
between the hindfoot and forefoot, the attitude of
anterior to the ankle and pushing the posterior
the heel, and range of ankle motion.
calcaneus medially by lateral pressure posterior
Anteroposterior and lateral radiographs should
to the ankle, ensuring the talar head does not
also be obtained.
externally rotate. In severe cases, the navicular
may not fully reduce although abduction of
the cuneiforms more distally will allow EXTENSIVE SOFT TISSUE RELEASE VIA
correction and the navicular–cuneiform joints THE CINCINNATI INCISION
will remodel. Once the calcaneocuboid
alignment is restored with the anterior calcaneus Preoperative planning
lateralized, correction of varus can be achieved.
The cast must be toe to groin with the knee in Indications
90° of flexion to maintain abduction and • Failed Ponseti treatment: 50 per cent may
external rotation. This will also treat any relapse at an average age of 2.5 years.
286 Paediatric orthopaedic surgery
Remanipulation and casting with or without metatarsal, curves below the medial malleolus,
Achilles tenotomy followed by splintage may rises slightly to traverse the Achilles tendon and
be successful although extensive soft tissue continues over the lateral malleolus to terminate
releases are required in resistant cases distal and medial to the sinus tarsi.
• Rigid clubfoot
• Walking on lateral border of foot/internally Superficial dissection
rotated gait
• Posteriorly placed lateral malleolus (a reflection Structures at risk
of uncorrected internal calcaneal rotation)
• Parallelism of talus and calcaneus on AP and • Sural nerve laterally
lateral radiographs. • Superficial venous structures below the lateral
malleolus
Contraindications
Previous releases via alternative incisions. The proximal subcutaneous flap is raised off
underlying tissues for around 3 cm to allow
Consent and risks proximal visualization.
including abductor hallucis. Beneath the navicular, Apply plaster of Paris from the toes to the mid-
the master knot of Henry (intersection of the flexor thigh with a neutral or slightly plantar flexed foot
hallucis longus [FHL] and flexor digitorum longus and the knee flexed to 90°.
[FDL]) is taken down, taking care not to damage
the medial and lateral plantar nerves either side of Postoperative care and instructions
it. The sheaths of the FDL and FHL are opened
and tendon Z-lengthening performed to prevent The cast is changed at 10 days after surgery, to
flexion contracture of the toes when the ankle is inspect wound. It is removed, along with the K-
dorsiflexed. This is done sufficiently proximally to wires, at 6 weeks. Denis Browne boots are
allow the lengthened portions to be covered by prescribed for the next 12–18 months.
tendon sheath. Conjoint lengthening is an Physiotherapy (for mobility, to promote tarsal
alternative if the tendons are too small to perform growth and preserve cartilage) is continued for at
Z-lengthening. This step may be unnecessary as least 6 months.
toe contractures will often stretch out over time.
The talonavicular joint is freed to mobilize the
navicular laterally and releasing all of its RECOMMENDED REFERENCES
attachments; keeping hold of it via the distal end
of tibialis posterior tendon will avoid handling the Ponseti I. Congenital Clubfoot: Fundamentals of
articular cartilage. The dorsal talonavicular Treatment. USA: Oxford University Press, 1996.
ligament and the spring ligament can then be Crawford AH, Marxen JL, Osterfield DL. The
released. Release of the bifurcate ligament and the Cincinnati incision: a comprehensive approach for
talocalcaneal interosseous ligament will allow surgical procedures of the foot and ankle in
external rotation of the anterior calcaneus. childhood. J Bone Joint Surg Am 1982;84:1355–8.
Finally, the quadratus plantae is stripped off the Dimeglio A, Benshahel H, Souchet P, et al.
calcaneus to release the long plantar ligament, the Classification of clubfoot. J Pediatr Orthop B
plantar calcaneocuboid ligament and inferior 1995;4:129–36.
medial capsule of the calcaneocuboid joint without McKay DW. New concept of and approach to
damaging the peroneus longus tendon. The clubfoot treatment: section II – correction of the
extensive soft tissue releases should result in the clubfoot. J Pediatr Orthop 1983;3:10–21.
plane of the foot being at 90° to the bimalleolar Pirani J, Outerbridge HK, Sawatzky B, et al. A
axis with the talus beneath the tibia and slight reliable method of clinically evaluating a virgin
hindfoot valgus. If the mortise is not fully reduced, clubfoot. 21st World Congress of SICOT, Sydney,
tibiofibular ligament release then tibiofibular Australia, 18–23 April, 1999.
syndesmosis release can be carried out if the talus is
too wide anteriorly. Stabilization with K-wires is
the final stage, one passing along the medial column
to hold the talonavicular joint and one across the SURGICAL TREATMENT OF PERTHES
lateral column to hold the calcaneocuboid joint. DISEASE
Closure Perthes disease occurs as a result of a temporary
Tendon sheaths over all over-lengthened tendons cessation in the blood supply to the femoral head
are closed. The medial and lateral extensions of leading to avascular necrosis. It is commonly seen
the Cincinnati incision are closed, without between the ages of 4 and 8 years although should
tension, using absorbable sutures to the be suspected from 2 to 12 years of age. Although
subcutaneous and subcuticular layers. The more common in boys by a factor of four, it may
posterior, central portion of the wound is left open be more severe in girls.
to heal by secondary intention. If blanching of Presenting symptoms comprise hip or referred
wound edges following tourniquet release is knee pain, stiffness, limping and a short leg. The
noted, position in less dorsiflexion. disease progresses through the four phases of
288 Paediatric orthopaedic surgery
PREOPERATIVE PLANNING
Figure 16.15 Illustration of hip arthrogram showing
Indications hinge abduction, where dye pools medially in abduction
The type of treatment largely depends upon the
capacity to remodel and therefore age. Below the
age of 6 years, there is high potential for
remodelling and therapy therefore tends to be Contraindications
conservative. Above 8 years, further remodelling is
Containment procedures are contraindicated if
limited and treatment is more aggressive in order
hips are not congruent or containable.
to correct deformity and extend the longevity of
the native hip.
Between the ages of 6 and 8 years, the Consent and risks
indications for either a conservative approach or
containment procedures depend upon bone age The natural history of the disease must be
and remodelling potential, the presence of ‘at-risk’ explained to the child and parents. It should be
signs for the viability of the femoral head and emphasized that the aim is to improve symptoms
whether the hip is congruent or containable. The and to achieve a spherical and contained femoral
surgical options for containable hips are a varus head to maximize and prolong native joint function.
osteotomy of the proximal femur and/or a Salter However, secondary degenerative changes may
type pelvic osteotomy. continue to occur at an unpredictable and
Salvage procedures are indicated if hinge accelerated rate ultimately leading to total joint
abduction occurs (Fig. 16.15), where the arthroplasty or arthrodesis.
overgrown and uncontained anterolateral portion • An older presentation, particularly in girls, is
of the femoral head abuts the lateral rim of the associated with a worse outcome
acetabulum. In this situation valgus extension • Stiffness/contractures
osteotomy (VGEO) of the proximal femur is • Other risks pertain to the type of procedure
indicated, which will medialize the centre of being performed. See the relevant sections on
rotation of the hip and make it congruent in the DDH for the risks associated with pelvic and
weightbearing position. The medial column must femoral osteotomies
be of sufficient height after reossification and a
better outcome is expected in younger patients Operative planning
where the triradiate cartilage remains open. This
will allow deformity correction, a better Various classification systems exist to guide
functional range of movement, improvement of treatment and predict the prognosis of Perthes
leg length and abductor function. disease.
Principles of surgery in cerebral palsy 289
Viva questions
1. What are the clinical signs of hip instability in 4. Describe the Smith–Petersen approach to the
the newborn? paediatric hip?
2. What are Hilgenreiner and Perkins lines and 5. What are the indications for varus proximal
what is their relevance? femoral osteotomy in developmental dysplasia
of the hip?
3. What are the relative advantages and
disadvantages of the anterior and medial 6. How does a varus proximal femoral osteotomy
approaches to the paediatric hip in affect range of hip movement and leg lengths?
developmental dysplasia of the hip?
292 Paediatric orthopaedic surgery
7. What structures are at risk during a Salter 14. What classification systems do you know for
pelvic osteotomy? grading the severity and predicting the
prognosis of Perthes disease?
8. What are the indications and contraindications
of the Pemberton pelvic osteotomy? 15. What are the component deformities of club
foot and which structures are tight?
9. What is the ideal screw position when pinning
a slipped upper femoral epiphysis? What risks 16. Which structures are at risk during extensive
are associated with this procedure? soft tissue release of congenital talipes
equinovarus via the Cincinnati approach?
10. What are the indications for prophylactic
17. How would you distinguish between a tight
pinning of the contralateral hip in slipped
tendo-Achilles complex and gastrocnemius
upper femoral epiphysis?
tightness?
11. How does the blood supply to the femoral 18. What methods can you describe to determine
head change throughout childhood? when epiphysiodesis should be performed?
12. What are the treatment options for avascular 19. How much growth per year can be expected
necrosis following slipped upper femoral from each of the four main physes in the
epiphysis? lower extremity in adolescence?
13. What is your approach to the treatment of 20. What is your approach to the orthopaedic
Perthes disease in a 7-year-old child? assessment and treatment of the child with
cerebral palsy?
17
Amputations
William Aston and Rob Pollock
Ideal amputation stump lengths, including the shortest and longest to allow adequate prosthetic
fitting and the increased energy expenditure by level
Indications Contraindications
‘Dead, dangerous or damn nuisance’ (Apley). This Inability to gain consent in a well-orientated
essentially means that if a limb is not viable due to patient in time, place and person.
disease or trauma, a danger to the patient due to
infection, crush injury or tumour, or non-
functional as a result of a congenital abnormality Consent and risks
or trauma and not amenable to other treatment
• Neurological pain
modalities, then amputation should be
• Phantom limb sensation
considered.
• Flap demarcation and necrosis necessitating
Indications by percentage are:
stump revision or vac pump application
• Peripheral vascular disease – 55 per cent
294 Amputations
Operative planning
Anteroposterior and lateral radiographs are used
for templating to determine the necessary bone I/4 length
resection level and clinical examination is vital to
plan satisfactory soft tissue closure with skin that
is sensate and that will heal normally. A priority is
adequate blood supply to the soft tissues to
enable this. Ideal and minimal resection levels
should be taken into account (see p. 293). Flap
lengths and their positioning, may have to be Figure 17.1 Amputation flap marking for equal anterior
altered to accommodate skin problems or tumour and posterior flaps. (a) Measurement of circumference
of limb at bony transection point with a suture –
excision. By doing this it may be possible to
length. (b) Marking medial and lateral apices. (c)
prevent a more proximal amputation.
Marking extent at flaps
through the deep fascia to form the skin flaps. At is sutured together over the end of the bone (Fig.
all times careful soft tissue handling techniques 17.2). A drain is inserted and the superficial fascial,
should be used. fat and skin layers closed separately. The skin can
be closed with absorbable or non absorbable
Deep dissection sutures as tissue healing should be normal.
In the ischaemic limb care should be taken to
The quadriceps muscle is divided, straight down keep the skin and muscle flap as one
to bone, in the line of the incision. The femoral myocutaneous flap and any tension on the tissues
canal is identified medial to the femur and the should be avoided, due to potential compromise
artery and vein ligated within it. These should be of the vascular supply and therefore myodesis
double tied proximally and if necessary a should not be used. Instead the muscle can simply
transfixion suture used. The periosteum is incised be sutured to the periosteum (myoplasty) or the
at the level of resection and the femur transected deep fascial layers of the muscle masses be
using a saw, ensuring protection of the soft tissues. sutured together over the end of the bone. Drain
A rasp is used to smooth the sharp edges of the insertion and layered closure is as above, except
cut bone and prevent high pressure areas in the the skin should be closed under no tension and
stump. The sciatic nerve is identified and interrupted non-absorbable sutures used.
transected, with a sharp blade under gentle A suitable stump dressing should be securely
traction, so that the end retracts proximally. Any applied, and this should remain in place for the
cutaneous nerves encountered should also be first 5 days.
transected in a similar fashion. The sciatic nerve
has a significant artery running within it and Technical aspects of procedure
therefore should be ligated, but this is not
necessary for other nerves. The hamstring In order to avoid large amounts of redundant soft
compartment is divided and the leg removed. The tissue the muscle flaps and skin flaps should be
wound should be washed thoroughly and the debrided as appropriate. However, a cylindrical,
tourniquet released to ensure adequate soft, well-padded soft tissue mass over the stump
haemostasis. is desirable. In some cases, such as when atypical
Assessment of the flaps is carried out and any flaps are used, the stump may be left large on
necessary trimming of muscle. In a non-ischaemic purpose to allow for possible skin demarcation
limb the quadriceps and the hamstrings can be and the potential for refashioning and closure. To
sutured (myodesis) through drill holes, to the avoid large dog-ears a stepwise approach to
bone, under slight tension. The deep muscle fascia closing the flaps is advised, starting by opposing
Myodesis sutures
Deep muscle
fascia sutures
Superficial
muscular
fascial sutures
(a) (b)
Figure 17.2 Femoral amputation stump – closure in layers. (a) myodesis sutures to bone. (b) Muscle fascial layer
closure
296 Amputations
Transection
point
Outline
of skin flaps
POSTOPERATIVE INSTRUCTIONS
Dressings are changed, with aseptic precautions,
at 3–5 days, looking specifically for signs of
infection or skin flap demarcation.
FOOT/RAY AMPUTATIONS
PREOPERATIVE PLANNING
Similar principles as for above knee amputation.
Closure
Dissection Interrupted non-absorbable sutures.
Create one full thickness flap, down to bone, to
prevent devascularization of the flap. Once the Transmetatarsal (midtarsal) amputation
bone has been reached, subperiosteal dissection
continues. The bone is transected, at the base of Landmarks and incision
the appropriate metatarsal, sloping the cut to the
A long plantar and shorter dorsal flap is used (Fig.
shape of the foot and to minimize pressure on the
17.6). The dorsal flap begins at the level of the
skin. Tendons are cut under tension and allowed
intended transection and curves distally as comes
to retract, ligate arteries and transect nerves.
medially. The plantar flap starts at the level of the
Technical aspects of procedure metatarsal heads and curves to meet the dorsal
incision medially and laterally.
Removal of the ray may be made easier if the
metatarsophalangeal joint is disarticulated first Dissection
and the metatarsal is removed separately. Note,
Skin and fat are incised in line with the skin. The
during disarticulation of the first metatarso-
metatarsophalangeal joints should be disarticu-
phalangeal joint, the penetrating branch of the
lated and toes removed. The levels of transection
dorsalis pedis should be preserved (approximately
of the metatarsals are marked and cut and edges
1 cm distal to the joint).
smoothed. The tendons are stretched and cut so
Closure that they retract proximally. Similarly, the nerves
are divided proximally and the digital arteries
A single layer of non-absorbable suture is used.
ligated then divided.
Central ray amputation Technical aspects of procedure
Longer flaps are required medially, due to
Landmarks and incision
increased thickness of the foot.
Dorsal incision with tennis racquet around the
toe. Closure
Interrupted non-absorbable single layer closure is
Superficial dissection all that is required.
Skin and fat to bone.
Deep dissection
Midfoot amputations
Subperiosteal dissection is done. Transection of These amputations use exactly the same
the base of the metatarsal leaving a remnant is principles as above. As opposed to a midtarsal
technically easier than disarticulation at the amputation, these amputations do not leave any
Foot/ray amputations 299
of the metatarsals behind. The Lisfranc talus is excised by placing the foot in equinus and
amputation is at the level of the tarsometatarsal sequentially dividing the anterior capsule, deltoid
joints and the Chopart amputation at the level of ligament and calcaneofibular ligament, taking care
the midtarsal joints. Lisfranc and Chopart to preserve the posterior tibial artery. After
amputations have a tendency to go into an division of the posterior capsule and the tendo-
equinovarus deformity with time. Achilles, the foot is removed by shelling out the
calcaneus and preserving the posterior flap.
Hindfoot amputation – Syme The distal tibia is transected 0.6 cm from the
amputation joint line, cut so that it will be parallel to the
ground, and the edges rounded off (see Fig. 17.7).
When considering performing a Symes amputa- The tendons are cut and allowed to retract
tion, a below knee amputation must also be proximally, as are the medial and lateral plantar
considered. A below knee amputation gives a nerves. The anterior tibial and posterior tibial
superior cosmetic result, enables better prosthetic arteries are ligated just proximal to the edges of
fitting and subsequent function. However, what a the flap. The heal pad is brought forward, over the
Symes does provide is a short leg and a stump
which can be used to mobilize short distances,
such as going to the bathroom in the middle of the
night, without having to hop or apply a prosthesis.
Tibial transection
Landmarks and incision Tip of
Malleolus
A single posterior heel flap is used. The incision is Front of ankle joint
from the tip of the lateral malleolus across the
ankle joint to 2 cm below the medial malleolus. It
continues vertically down around the heal, and
back to the tip of the lateral malleolus (Fig. 17.7).
Dissection
Skin and fat are incised in line with the skin. All Figure 17.7 Syme amputation: incision and tibial
structures are then transected down to bone. The transection point
300 Amputations
cut surface of the tibia, and sutured through drill Falstie-Jensen N, Christensen KS, Brochner-
holes on the anterior surface of the tibia. Mortensen J. Long posterior flap versus equal
sagittal flaps in below-knee amputation for
Technical aspects of procedure ischaemia. J Bone Joint Surg Br 1989;71:102–4.
The skin flap should not be excessively trimmed Hagberg E, Berlin OK, Renstrom P. Function after
as it may devascularize it. The dog-ears will through-knee compared with below-knee and
resolve over time, with bandaging or further above-knee amputation. Prosthet Orthot Int
procedure. 1992;16:168–73.
Halbert J, Crotty M, Cameron ID. Evidence for
Closure the optimal management of acute and chronic
A drain is inserted and the skin closed over it, phantom pain: a systematic review. Clin J Pain
using interrupted nylon sutures. 2002;18:84–92.
Harris RI. Syme’s amputation: the technique
POSTOPERATIVE CARE AND essential to secure a satisfactory end-bearing
INSTRUCTIONS (FOR ALL FOOT/RAY stump. Can J Surg 1964;7:53–63.
AMPUTATIONS) Hudson JR, Yu GV, Marzano R, et al. Syme’s
amputation. Surgical technique, prosthetic
• Partial or non-weightbearing is dependent on
considerations, and case reports. J Am Podiatr Med
the procedure.
Assoc 2002;92:232–46.
• Physiotherapy/prosthetic referral is
Malawer MM, Sugarbaker PH. Musculoskeletal
recommended at an early stage.
Cancer Surgery Treatment of Sarcomas and Allied
Diseases. London: Kluwer Academic Publishers,
RECOMMENDED REFERENCES 2001.
Pardasaney PK, Sullivan PE, Portney LG, et al.
Advantage of limb salvage over amputation for
Byrne RL, Nicholson ML, Woolford TJ, et al.
proximal extremity tumours. Clin Orthop Relat
Factors influencing the healing of distal
Res 2006;444:201–8.
amputations performed for lower limb ischaemia.
Br J Surg 1992;79:73–5.
Viva questions
1. What are the indications for amputation? 6. How do you transect a nerve?
2. What are the ideal amputation levels in long 7. What are the complications associated with
bones and why? amputation? How can these complications be
minimized?
3. How does the surgical technique differ when
performing an amputation on an limb with 8. What measures would you take to minimize
vascular disease? postoperative pain?
4. How would you decide on the appropriate level 9. How would you decide between a Syme and a
for an amputation? below knee amputation?
5. Describe above or below knee, or toe or foot/ray
amputations.
Index
A1 pulley amputations 293–300
trigger finger 141, 142 arm 293
trigger thumb 143 foot 297–300
AAOS classification of acetabular bone loss at revision leg 293–7
hip surgery 160 anaesthesia
abductor pollicis longus (APL) examination under see examination under
in de Quervain’s decompression 106, 107 anaesthesia
in wrist arthroscopy 101 postoperative 5
above elbow (transhumeral) amputation 293 pre/intraoperative 4
above knee (transfemoral) amputation 293, Silverskiold test under 283
293–6 analgesia 4–5
acetabular dysplasia 273 anconeus in elbow arthrolysis 82, 83
acetabulum angiography, coronary 2
in hip arthrodesis, preparation 164 angular limb deformity 260
in hip resurfacing, preparation 162 ankle 218–29
in total hip arthroplasty arthrodesis see arthrodesis
preparation 150–1 arthroplasty 220–2
removal of prosthetic component 159–60 arthroscopy 222–4
technical points about insertion of prosthetic range of motion 218
component 151–2 annular ligament in radial head replacement 91
trial insertion of prosthetic component 150–1 arm amputation 293
see also femoroacetabular impingement surgery arthritis
Achilles tendon degenerative see osteoarthritis
in calcaneal osteotomy 255, 256 rheumatoid, trigger finger 141
lengthening 281–4 arthrodesis (fusion)
in talipes equinovarus 285 ankle 218–20, 230–2
tendinopathy 224–6 triple, in cerebral palsy 291
acromioclavicular joint cervical spine, risks 15
excision 65–6 foot 230–2
reconstruction 69–70 distal interphalangeal joints 247–8
acromioplasty, open anterior 62–4 first metatarsophalangeal joint 242–4
adductor(s), hip first tarsometatarsal joint 239–40
adductor longus anatomical relationships (in surgery hindfoot 252–4
for developmental dysplasia of hip) 270 proximal interphalangeal joints 248–9
release in cerebral palsy 290 hand 121–4
adductor pollicis release in cerebral palsy 290 hip 163–4
adductus deformity in talipes equinovarus 285 knee 197–8
adhesions, flexor tendon repair 132 lumbar spine 37
age see children; infants; older and elderly people malunion see malunion
airway non-union see non-union
chronic obstructive disease 3 thoracic spine
preoperative assessment 1–2 anterior 26–8
Akin osteotomy 237–8 posterior 28–30
American Academy of Orthopedic Surgeons (AAOS) wrist 102–6
classification of acetabular bone loss at revision hip arthrography, hip 170–1
surgery 160 Perthes disease 289
302 Index