CHAPTER 43 ORTHOPEDIC SURGERY
anterior approach (Smith Petersen), anterolateral approach
6. JOINT RECONSTRUCTION
Arthritis refers to a large number of medical conditions
including osteoarthritis, rheumatoid arthritis, septic arthritis,
and posttraumatic arthritis.
-causes pain, loss of range of motion, decreased ability to
perform work duties or participate in social functions
Examination of the Patient
-history and physical examination
-begin by observing the patient’s gait
Typical gait patterns include antalgic gait due to pain, or a
“Trendelenburg gait” where abductor weakness may lead to a
poor outcome following total hip arthroplasty.
Diagnostics: Advanced imaging, including CT and MRI
Nonoperative Management and Prevention of Arthritis
- weight loss, activity modification, rest, physical therapy,
NSAIDs, bracing, and assistive devices
Treatment: nonoperatively prior to recommending surgery.
Prevention: Health and exercise
Injections: knee and shoulder
Common injections :corticosteroids, hyaluronic-acid gels.
Diagnostic hip injections are particularly helpful in
distinguishing pain resulting from hip versus lumbar spine
pathology.
-viscosity of the synovial fluid (hyaluronic Acid)
Short-term altered glucose metabolism in diabetic patients is
common with corticosteroid injections.
Surgical Management of Arthritis
Most common procedure: arthroplasty, or joint replacement.
Joint replacements: hip and knee arthroplasty
Osteotomy- cutting of the bone to change the position of the
fragments improving rotation, alignment, or angulation.
-performed for both congenital and acquired deformities -
-Femoral osteotomies to correct version and varus/valgus
deformity of the femoral neck.
-proximal tibia osteotomy-commonly used
Arthrodesis -treatment option for severe arthritis
Ankle arthrodesis is the primary procedure performed in adult
patients with traumatic arthritis of the ankle.
Joint Arthroplasty/Joint Replacement- is the most common
option for patients suffering from pain associated with
arthritis in a joint.
Hip Arthroplasty is utilized for end stage arthritis
Conventional hip arthroplasty refers to total hip arthroplasty
-hemiarthroplasty describes the replacement of the femoral
head and neck with a stemmed femoral component
History of Hip Arthroplasty (hip replacement) may be broken
down into “Pre-Charnley” and “Post-Charnley”
Fracture of the interposed material often led to failure
Surgical Approaches to the Hip:
(Watson-Jones), lateral approach (Hardinge), and posterior
approach (Kocher Langenbach).
Anterior approach (Smith Petersen): internervous and
intermuscular approach. It utilizes the internervous plane
between the femoral nerve and superior gluteal nerve.
Advantages: supine positioning, use of intraoperative
fluoroscopy for acetabular component positioning, and
discontinuation of all ambulatory assistive devices 1 week
earlier than other approached.
Posterior approach (Kocher–Langenbach)
- muscle-splitting approach without an internervous plane.
After incising the skin and subcutaneous fat, the fascia lata is
incised along with the gluteus maximus.
Lateral approach (Hardinge):
-Care must be taken to protect the superior gluteal nerve
during this exposure, which lies 5 cm proximal to the tip of
the greater trochanter.
-Exposure of the acetabulum is excellent with the modified
Hardinge approach
Bearing Surfaces in Hip Arthroplasty
The most common combination of bearing surfaces used in
total hip arthroplasty is a metal (generally cobalt chrome) or
ceramic prosthetic head, articulating with a polyethylene liner.
Alignment of Hip Arthroplasty Components
Proper alignment of hip arthroplasty components is vital to a
successful procedure and patient outcome.
-This is accomplished with combined version of the femoral
and acetabular components, appropriate abduction of the
acetabular components
Knee Arthroplasty
- indicated for end-stage arthritis that has failed a reasonable
trial of nonoperative measures
-unicompartmental knee arthroplasty consists of replacing one
compartment of the knee, most commonly the medial
compartment.
Surgical Approach to the Knee
Total knee arthroplasty ( medial parapatellar approach).
- utilizes a longitudinal skin incision extending, on average,
5cm proximal to the patella to the medial aspect of the
tibial tubercle distally. Dissection is carried down to the
capsule.
Bearing Surfaces in Knee Arthroplasty
-The femoral component consists of a metal prosthetic cap
-The tibia is cut perpendicular to the anatomic and mechanical
axis
Two types of primary total knee arthroplasty:
1. cruciate retaining systems- the PCL is retained in hopes of
preserving more normal knee structures and minimizing bone
loss
2. posterior stabilized systems-the ligament is sacrificed and
the components are designed to accommodate for the loss.
Alignment and Balancing in Knee Arthroplasty
Appropriate sizing and positioning of the components and
balancing of the size and geometry of bony gaps in flexion
and extension are essential for a successful knee arthroplasty.
Computer Navigation, Robotics, and Joint Arthroplasty
has the theoretical benefit of more accurate and consistent
placement of arthroplasty components through intraoperative
feedback to the surgeon regarding component position,
planned bone cuts, and alignment.
Disadvantage: increased costs of the technology, prolonged
operative times, and risk of infection/fracture at the sites of
intraoperative sensor placement within bone. Use of computer
navigation in total joint arthroplasty has been shown
to minimize outliers in alignmen
Fixation Options in Joint Arthroplasty
Components in hip and knee arthroplasty can be secured with
cement or biologic fixation.
-polymethylmethacrylate (PMMA)- most commonly used
Osteolysis and Aseptic Loosening.
-Osteolysis is a term used to describe abnormal resorption of
bone caused by underlying infection, metastatic disease, or in
case of joint replacement
-Activated macrophages lead to an osteolytic process and
bone resorption.
-A substantial osteolytic response may occur and lead to
component micromotion and aseptic loosening
Complications in Joint Arthroplasty
The risk of any complication following joint arthroplasty
procedures falls in the range of 5% to 10%.
Risks include infection, intraoperative or postoperative
fracture, vascular injury,blood transfusion, nerve injury or
nerve palsy
Dislocation Following Hip Arthroplasty.
Component position should be assessed in patients with
multiple dislocations.
7. ORTHOPEDIC PATHOLOGY AND ONCOLOGY
Diagnosis: History, PE
Patient age can help in establishing a differential.
Round blue cell lesions :neuroblastoma in a 5-year-old
10-year-old: Ewing’s sarcoma
20-year-old: Lymphoma
60-year-old: myeloma
Giant cell tumor is more common in females while
osteosarcoma is more common in males.
Laboratory Tests: LDH, Ca, ALP, PSA
Imaging: Xray, US, Ct, MRI
Biopsy: FNAB, FNAC, OPEN
OSTEOSARCOMA- most common primary malignant bone
tumor
-classified as osteoblastic, chondroblastic, fibroblastic,
telangiectatic, round cell, or MFH-like
Common in 10 and 20 years of age
Common around the knee
Secondary osteosarcomas occur in older patients affected by
Paget’s disease, radiation, or bone infarct.
Treatment: wide resection, with or without chemo
1. Intramedullary Osteosarcoma
most common primary sarcoma of the bone.
-Young patients may present with pain and swelling, with
X-rays showing plastic lesions in some areas of destruction
with periosteal reaction called “Codman’s Triangle.”
Diagnostics: X-rays ,MRI, CT scans of the chest are usually
done to find primary metastases.
-confirmed with a biopsy
Treatment: preoperative chemotherapy and wide resection,
followed by postoperative chemotherapy.
2. Parosteal Osteosarcoma
- low-grade surface osteosarcoma
Ddx:osteochondroma and myositis ossificans.
Treatment: consists of wide excision.
Prognosis: is 95% 5-year survival, low-grade tumor.
3. Periosteal Osteosarcoma
- is a high-grade tumor. It occurs on the anterior surface of the
distal femur or proximal tibia.
-The lesion appears chondroblastic on histology.
Radiographs show scalloping of the underlying cortex with a
“sunburst” periosteal reaction.
Treatment: chemotherapy and wide surgical excision.
The 5-year survival rate is 80%.
Paget’s Sarcoma
Paget’s sarcoma is a rare complication of Paget’s disease.
and skull and occurs < 1% of patients.
Imaging may demonstrate osteolytic areas and loss of normal
fatty marrow and multifocal lesions.
Treatment: chemotherapy and wide surgical excision.
Radiation-Induced Sarcoma
The three criteria are (a) histology different from the original
lesion, (b) sarcoma develops in the irradiated field, and (c) a
3- to 5-year latent period between radiation and sarcoma
development.
Treatment: combination of chemotherapy and surgery.
EWING’S SARCOMA
the second most common primary bone <30 y.o.
Characteristic onion skin periosteal reaction on xray
Small round blue cell tumor
Treatment: chemo or radio and surgical
Diagnosis confirmed with bone marrow biopsy specimen.
Bone scan can identify multiple lesions.
CARTILAGE-FORMING TUMORS
Chondrosarcomas- third most common primary bone
malignancies.
>40 years of age: common
Clear cell chondrosarcoma and mesenchymal chondrosarcoma
occur in younger patients
Treatment: surgical excision
FIBROUS LESIONS OF BONE
Desmoplastic Fibroma
Desmoplastic fibroma is a rare tumor occurring in the
mandible, femur, pelvis, radius, or tibia in young adults.
-Presents as a painful lesion
Radiographs show a metadiaphyseal “soap bubble”
appearance and endosteal scalloping.
Histology resembles desmoid tumors or fibromatosis.
Treatment: wide excision to avoid recurrence.
Malignant Fibrous Histiocytoma of Bone
occurs in the metadiaphysis of long bones
-present with pain or by a pathologic fracture
- Radiographs typically show destructive lesions with
soft-tissue extension.
Histology resembles osteosarcoma with pleomorphic spindle
cells, histiocytes,
and giant cells, but no neoplastic osteoid formation.
Treatment: chemotherapy and wide surgical excision.
Malignant Vascular Tumors
Hemangioendothelioma is a malignant neoplasm arising
from vascular endothelium in long bones and most often
occurs in the lower extremity.
Radiographs show a metadiaphyseal lytic lesion with a “soap
bubble” appearance.
Treatment:curettage for low-grade lesions and wide excision
+/- radiation therapy for high-grade lesions.
Hemangiopericytoma.
usually a solitary lesion occurring in the soft tissues or the
axial skeleton and proximal long bones in middle-aged
Histology reveals branching “staghorn” vascular spaces.
Treatment:wide excision.
Angiosarcoma of Bone.
is a soft tissue malignancy usually seen in older adult males;
chronic vascular stasis
Histology reveals vascular channels with anaplasia.
Treatment:wide excision
MISCELLANEOUS TUMORS
Giant Cell Tumor of Bone
Common in Females 20-40 y.o.
occur around the knee, distal radius, proximal humerus, pelvis
Giant cell tumors
Presenting complaints include pain and pathologic fracture.
Histology reveals multinucleate giant cells
Treatment:curettage and high-speed burr.
Adamantinoma and Osteofibrous Dysplasia
low-grade malignant tumors usually seen in the tibia.
-May metastasize to the lung. The patient may present with
pain and/or bowing of the tibia. X-ray reveals multiple lucent
lesions on the cortex of the tibia.
Histology reveals a biphasic tumor with nests of epithelial
cells and fibrous stroma
Osteofibrous dysplasia is considered the precursor to
adamantinoma and usually occurring in children
Treatment: wide surgical Excision
Primary Lymphoma of Bone.
Chordoma
-arises from notochordal remnants in the sacrum.
It is usually midline in location. These tumors are found in
middle-aged to older men
Visualization of the lesion may be difficult because of the
bowel gas shadow.
Diagnosis : MRI shows a destructive extensile midline lesion
with a large soft tissue mass.
Histology shows epithelioid cells arranged in cords with
vacuolated foamy physaliferous cells. These cells are keratin
positive.
Treatment: surgical excision and muscle flaps and
a mesh for reconstruction.
Multiple Myeloma
- most common primary bone malignancy, is a proliferative
disorder of B cells with plasma cells producing
immunoglobins.
-have a classic eccentric nucleus giving a “signet ring”
appearance
Plasmacytoma is a solitary tumor with a negative bone
marrow biopsy, usually treated with radiation to the lesion.
Myeloma is treated with bisphosphonates, chemotherapy,
METASTATIC BONE TUMORS
- more common than primary bone tumors which affect the
lung, liver, and bone.
Sources: breast, lung, thyroid, kidney, and prostate.
> 40 y.o
-Biopsy to rule out primary bone lesions
Treatment: Metastatic tumors are usually treated by
bisphosphonates and surgical stabilization with postoperative
radiation
8. PEDIATRIC ORTHOPEDICS:
Brachial plexus injury during Birth
A. Neonatal Brachial Plexus Palsy.
-occurs in 2 births in every 1000
-usually represents a stretch injury on the nerve roots of the
upper or lower plexus
Risk factors: Large birth weight, forceps delivery, breech
presentation, and prolonged second stage of labor with
shoulder dystocia
Upper plexus injuries (Erb-Duchenne) are lesions
manifested by weakness of shoulder abductors, external
rotators and elbow flexors.The hand is not involved. It has a
good prognosis
Lower plexus injury, the hand is involved, with deformity of
the fingers. An ipsilateral Horner’s Syndrome consisting of
ptosis, myosis, anhidrosis, and enophthalmos may occur
indicating a preganglionic injury of the T1 cervical
sympathetic nerve. This condition has a poor prognosis.
Management: therapy and gentle, passive range-of motion
exercises to preserve motion in the shoulder and prevent
muscle contractures and joint in congruency in the early
neonatal period
Early surgical intervention for brachial plexus: infants who
did not recover elbow flexion by 3 months of age
Surgical intervention: microsurgical repair procedures
Later orthopedic reconstruction: muscle rebalancing
B. Cerebral Palsy
- results from an injury to the brain associated with mental
impairment.
-increased muscle tone and hyperreflexic muscles
-classified as spastic, athetotic, or ataxic
-present with spasticity, hemiplegia, diplegia, or scoliosis.
Treatment:tendon lengthening procedures,contractures,
tendon transfers to maintain motion and function.
Hip dislocation or subluxation- results from unbalanced
muscle forces in many cerebral palsy patients.
Early treatment: form of adductor tendon releases, iliopsoas
releases, and immobilization in an abduction brace.
Older children w/ severe deformity: bony procedures in the
form of open reduction and femoral or acetabular osteotomies
Femoral head resection: salvage procedure in
nonambulatory patients with painful dislocated hips.
Knee flexion contractures are treated with hamstring muscle
lengthenings and immobilization in knee extension braces.
Equinovalgus foot: most common foot deformity in cerebral
palsy caused by heel cord contracture and peroneal spasm.
Skeletal Growth
-Injury, inflammatory disease, and developmental disorders in
actively growing bones the growth plates.
Physis is divided into specific zones: the reserve zone, the
zone of proliferation, and the hypertrophic zone.
Hypertrophic zone has three phases: maturation zone, the
degenerative zone, and the zone of calcification
Periosteum: Surrounding the metaphyseal and diaphyseal
bone.
Pediatric Fractures
In a pediatric patient, the epiphyseal growth plate is unossified
and weak and is at risk of fracture. Reduction and stabilization
of epiphyseal fractures is critical to minimize permanent
growth disturbances and deformity. Fractures near the growth
plate have significant potential to remodel
Classification of Growth Plate Injuries
1. Salter-Harris type I injury is a simple transverse fracture
through the physis.
2. Salter-Harris type II fracture contains a component of
fracture through the growth plate in continuity with a fracture
of the metaphysis.
3. Salter- Harris type III fracture occurs through the
epiphysis and exits through the growth plate,
4. Salter-Harris type IV fracture extends through the physis
from the metaphysis into the epiphysis.
5. Salter-Harris type V fracture is a crushing injury to the
physis. Type III and type IV involve the joint.
Treatment:anatomic reduction of the fragments (closed or
open)
Distal femur physeal fractures will need an anatomical
reduction and close follow-up
Complication: physeal arrest resulting in leg length
discrepancy
(LLD) and/or angular deformity.
Diaphyseal Injuries in a Pediatric Patient
Pediatric patients: capable of extensive remodeling
10° angulation in both bones of the forearm in a child over an
age of 10 years may cause significant limitation of rotation of
the forearm
Treatment:When internal fixation of a diaphyseal fracture is
required, fixation through the physis is avoided.
Fractures of the Pediatric Hip
-occur with high-energy trauma, avascular necrosis
Treatment:spica cast
Closed or open reduction and internal fixation is done in
fractures with severe displacement.
Complication: Avascular necrosis
Fractures of the Femoral Shaft
-Consider child abuse if a femoral shaft fracture occurs before
the walking age.
Treatment: Femoral shaft fractures in a child <6 months
(Pavlik harness or spicacast)
-between 5 years and 11 y.o ( surgery)
-fracture is transverse (flexible IM nails)
- fracture is too proximal/too distal: submuscular bridge plate
>11years:interlocking IM rod + lateral trochanteric entry
-between 2 and 10 years of age:Overgrowth of the injured
femur with leg length discrepancy
Pediatric Ankle Fractures
-Salter-Harris type I and type II usually involve the fibula.
( present with pain and swelling)
-Salter-Harris type III usually : fracture of the medial
malleolus or avulsion of the anterior inferior tibiofibular
ligament from the tibia ( Tillaux fracture).
-Triplane fractures are complex ankle fractures in older
children as a result of partial closure of the growth plate
- Salter-Harris I and II fractures are usually managed with
casting.
-Salter-Harris III or IV fractures are usually managed by
closed or open reduction and internal fixation.
Pediatric Elbow Fractures
Distal humeral physeal separation occur from child abuse and
can be mistaken for an elbow dislocation.
Treatment:lateral condylar fracture of the elbow (need
anatomical surgical reduction.
-Medial epicondyle fractures treated conservatively.
-open reduction, and percutaneous pinning is usually done for
these fractures. .
Close follow-up for maintenance of reduction and
neurovascular status is needed.
DEVELOPMENTAL DISEASE
Developmental Dysplasia of the Hip
- dysplasia, subluxation, or dislocation of the hip.
- Developmental dysplasia of the hip is most often seen in
firstborn females with a positive family
-Untreated hip dislocations can lead to a dysplastic
acetabulum,
-Within the first 72 hours (for hip instability)
Ortolani’s test:gentle elevation and abduction of the femur
Barlow’s test is gentle adduction and depression of the femur
Diagnostics: Ultrasound
Treatment of DDH
• Neonate to 6 months: Early treatment with abduction and
flexion in a Pavlik harness for 6 to 12 weeks
• Children 6 to 18 months: Closed reduction and application
of hip spica cast
• Children older than 18 months: Open reduction and
capsulorrhaphy
-Talipes equinovarus can be corrected by sequential corrective
casting of the foot. The serial manipulationand the casting
technique is called the Ponseti technique
-A successful program of casting may be complete in 1 to 5
months.
- posteromedial soft tissue release and tendon lengthening.
Osgood-Schlatter Disease
- seen in athletically active adolescents (sprinters and
jumpers)
- a traction apophysitis of tibial tubercule
-it is characterized by ossification in the distal patellar tendon
at the point of its tibial insertion, and it is thought to result
from mechanical stress on the tendinous insertion and presents
with
severe local pain and tenderness in the area of the tibial
tubercle.
-Radiographs may show calcified ossicles within the tendon at
its insertion.

Legg-Calvé-Perthes Disease
-Legg-Calvé Perthes: flattening of the femoral head
-Age presentation: between 4 and 8 years, occurs in male
< 6 years old: better prognosis. The patient presents with groin
or knee pain, decreased hip motion, and a limp.
-Treatment : traction, physical therapy, abduction exercises,
and crutches.

Slipped Capital Femoral Epiphysis

-10 to 16 y.o: develop displacement of the epiphysis on the
femoral neck with no history of injury.
-The slippage occurs through the weak zone (hypertrophic
zone) of the growth plate.
Slipped capital femoral epiphysis (SCFE) is associated with
African-American heritage and obesity, and it is more
common in boys than in girls.

Patient may present with knee pain

- classified as either stable or unstable
1. Stable if the patient is able to bear weight and the risk
of osteonecrosis is less than 10%.
2. Unstable if the patient is unable to bear weight even with
crutches, and the incidence of avascular necrosis is high.
Treatment:percutaneous screw fixation through the femoral
neck

Lower Extremity Rotational Abnormalities

Intoeing can result from femoral anteversion, tibial torsion,
and metatarsus adductus
- Severe rotation with functional impairment that does not
correct by age 10 or 11 may require rotational femoral
osteotomy.
-Tibial torsion is the most common cause of intoeing in
toddlers and could be bilateral.

Congenital Talipes Equinovarus (Clubfoot)

- a congenital disorder, and its etiology is not known.
-Clubfoot is a common problem associated with contractures
of the medial tendons of the foot