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In Memory of

Rocco A. Calandruccio
19232007

Peter G. Carnesale
19372006

Marcus J. Stewart
19112007

Since the last edition of this text, we have been saddened by the loss of three of our
colleagues, friends, and mentors. Each of these outstanding orthopaedic surgeons was a
leader, innovator, teacher, and role model, and we have valued their wisdom and
experience, which they so generously shared with us personally and with so many
others through their contributions to several editions of Campbells Operative Orthopaedics.
We all will miss their advice and counsel and their dedication to our profession.

Dedication to
Campbell Foundation personnel
whose skills and dedication
make this work a reality
Kay Daugherty, Medical Editor
Linda Jones, Medical Editor
Barry Burns, Graphic Artist and Videographer
Joan Crowson, Librarian

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Contributors

Frederick M. Azar, MD
Professor and Residency Program
Director
Director, Sports Medicine Fellowship
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
James H. Beaty, MD
Professor, Department of Orthopaedic
Surgery
University of TennesseeCampbell
Clinic
Chief of Staff, Campbell Clinic
Memphis, Tennessee
James H. Calandruccio, MD
Associate Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
Francis X. Camillo, MD
Assistant Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
S. Terry Canale, MD
Harold B. Boyd Professor and Chairman
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
Kevin B. Cleveland, MD
Instructor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Andrew H. Crenshaw, Jr., MD


Associate Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Raymond J. Gardocki, MD
Instructor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

John R. Crockarell, Jr., MD


Associate Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

James L. Guyton, MD
Assistant Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Patrick M. Curlee, MD
Instructor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

James W. Harkess, MD
Assistant Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Gregory D. Dabov, MD
Assistant Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Robert K. Heck, Jr., MD


Assistant Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Jeffrey A. Dlabach, MD
Instructor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Susan N. Ishikawa, MD
Assistant Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Barney L. Freeman III, MD


Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Mark T. Jobe, MD
Associate Professor
Department of Orthopaedic Surgery
University of Tennessee-Campbell
Clinic
Memphis, Tennessee

vii

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viii

Contributors

David G. LaVelle, MD
Associate Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Barry B. Phillips, MD
Associate Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Santos F. Martinez, MD
Physical Medicine and Rehabilitation
Campbell Clinic
Memphis, Tennessee

Robert M. Pickering, MD
Assistant Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Marc J. Mihalko, MD
Instructor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
Robert H. Miller III, MD
Associate Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
G. Andrew Murphy, MD
Assistant Professor
Co-Director, Foot & Ankle Fellowship
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
Ashley L. Park, MD
Clinical Assistant Professor
Department of Internal Medicine,
Division of Rehabilitation Medicine
University of Tennessee College of
Medicine
Memphis, Tennessee

David R. Richardson, MD
Instructor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
E. Greer Richardson, MD
Professor
Co-Director, Foot & Ankle Fellowship
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
Jeffrey R. Sawyer, MD
Instructor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
William C. Warner, Jr., MD
Associate Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

A. Paige Whittle, MD
Associate Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Chief of Orthopaedics, Veterans
Administration Hospital
Memphis, Tennessee
Keith D. Williams, MD
Assistant Professor
Director, Spine Fellowship
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
Dexter H. Witte, MD
Clinical Assistant Professor of Radiology
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee
George W. Wood II, MD
Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Chief of Orthopaedics, Regional
Medical Center
Memphis, Tennessee
Phillip E. Wright II, MD
Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

Edward A. Perez, MD
Assistant Professor
Department of Orthopaedic Surgery
University of TennesseeCampbell
Clinic
Memphis, Tennessee

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Preface

As we begin work on each new edition, we are always


amazed that the eld of orthopaedic surgery continues to
produce so many innovative techniques and equipment
year after year. As with each edition, we have tried to make
sure this 11th edition is as comprehensive, up-to-date, and
pertinent to your practice as possible by including triedand-true procedures along with the promising newer
techniques.
A number of new features have been added in this
edition that we hope will make it more user-friendly.
The technique descriptions are highlighted with color for
quick identication and bulleted for easy reading. Hundreds
of color photographs, including intraoperative photographs,
have been added to illustrate diagnostic and treatment principles, and color has been added to the line art to emphasize important structures and techniques. The number of
video clips has been expanded to include more frequently
used but technically difcult procedures, including total
elbow arthroplasty, mini-incision total knee arthroplasty,
and shoulder arthroscopy. The techniques demonstrated on
the DVD are listed on the end sheets at the front and back
of this book for easy access and reference.
An exciting addition to this edition is its availability as
a multimedia reference source. In addition to the revised
and up-dated four-volume text, a fully searchable on-line
edition will provide instant access to regular updates, an
image library for electronic presentations, and links to
abstracts of references. We believe these resources will

greatly expand the ways in which Campbells Operative


Orthopaedics can help physicians ensure the highest quality
of care for their patients.
We are, as always, greatly indebted to our contributors
for their hard work in reviewing and revising each chapter.
This requires large amounts of time out of their professional and personal lives, and we are grateful for their
commitment to making each edition better than the last.
Our thanks also to the Campbell Foundation personnel
Kay Daugherty, Linda Jones, Barry Burns, and Joan
Crowsonfor amassing all the raw material from 35
authors and turning it into readable text with illustrative
art, photographs, and videos. Without their hard work, the
hundreds of folders stuffed with paper would never have
evolved into this text. Our deepest appreciation goes to
our patient and supportive spouses, Sissie Canale and Terry
Beaty, who endured our struggles with the constant deadlines with grace and humor.
Because of their hard work in amassing all the raw
material from 35 authors and turning it into readable text
with illustrative art, photographs, and videos, we dedicate
this edition to the Campbell Foundation Research and
Publication personnel. Without their hard work, the hundreds of folders stuffed with paper would never have
evolved into this text.
James H. Beaty, MD
S. Terry Canale, MD

ix

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Surgical Techniques
and Approaches
ERRNVPHGLFRVRUJ
Andrew H. Crenshaw, Jr.

Surgical Techniques .................... 4


Tourniquets ..................................... 4
Radiographs in the Operating
Room ........................................... 6
Positioning of the Patient ............... 6
Local Preparation of the Patient ..... 7
Wound Irrigating Solutions ..................... 9
Draping ............................................ 9
Draping the Edges of the Incision ........... 10
Prevention of Human
Immunodeciency Virus
Transmission ............................... 10
Special Operative Techniques ........ 11
Fixation of Tendon to Bone ................... 11
Fixation of the Osseous Attachment of
Tendon to Bone ............................... 13
Bone Grafting ..................................... 14

Surgical Approaches................... 23
Toes ................................................ 24
Approach to the Interphalangeal Joints...... 24
Approaches to the Metatarsophalangeal
Joint of the Great Toe ....................... 24
Approach to the Metatarsophalangeal
Joints of the Lesser Toes .................... 25
Calcaneus ........................................ 25
Medial Approach ................................. 25
Lateral Approach ................................. 25
U Approach ........................................ 25
Kocher Approach (Curved L).................. 27
Tarsus and Ankle ........................... 27
Anterolateral Approach .......................... 27
Anterior Approach ................................ 28
Kocher Lateral Approach to the Tarsus
and Ankle ...................................... 29
Ollier Approach to the Tarsus ................ 29
Posterolateral Approach to the Ankle ........ 30
Anterolateral Approach to the Lateral
Dome of the Talus ........................... 30
Posterior Approach to the Ankle.............. 31
Medial Approaches to the Ankle ............. 32
Tibia ............................................... 32
Anterior Approach ................................ 32
Medial Approach ................................. 33
Posterolateral Approach.......................... 33

Posterior Approach to the Superomedial


Region of the Tibia .......................... 33
Fibula .............................................. 35
Posterolateral Approach.......................... 35
Knee ............................................... 36
Anteromedial and Anterolateral
Approaches...................................... 36
Anterolateral Approach .......................... 39
Posterolateral and Posteromedial
Approaches...................................... 40
Medial Approaches to the Knee and
Supporting Structures ........................ 42
Transverse Approaches to Menisci ............ 43
Lateral Approaches to the Knee and
Supporting Structures ........................ 45
Extensile Approaches to the Knee ........... 48
Posterior Approaches ............................. 51
Femur ............................................. 52
Anterolateral Approach .......................... 52
Lateral Approach ................................. 55
Posterolateral Approach.......................... 55
Posterior Approach ............................... 56
Medial Approach to the Posterior Surface
of the Femur in the Popliteal Space ..... 58
Lateral Approach to the Posterior Surface
of the Femur in the Popliteal Space ..... 58
Lateral Approach to the Proximal Shaft
and the Trochanteric Region ............... 58
Hip ................................................. 60
Anterior Approaches ............................. 60
Anterolateral Approach .......................... 63
Lateral Approaches ............................... 63
Posterolateral Approach.......................... 69
Posterior Approaches ............................. 73
Medial Approach ................................. 74
Acetabulum and Pelvis ................... 75
Anterior Approaches ............................. 75
Posterior Approach ............................... 79
Extensile Acetabular Approaches ............. 81
Extended Iliofemoral Approach .............. 81
Ilium ............................................... 89
Ischium ........................................... 90
Symphysis Pubis ............................. 90
Sacroiliac Joint................................ 90
Posterior Approach ............................... 90
Anterior Approach ................................ 91

Chapter 1

Both Sacroiliac Joints or Sacrum... 91


Spine ............................................... 92
Sternoclavicular Joint ..................... 92
Acromioclavicular Joint.................. 92
Shoulder.......................................... 92
Anteromedial Approaches ....................... 92
Anterior Axillary Approach.................... 94
Deltoid-Splitting Approach ..................... 95
Transacromial Approach ......................... 95
Posterior Approaches ............................. 96
Posterior Inverted U Approach ................ 99
Humerus ....................................... 100
Anterolateral Approach ........................ 100
Posterior Approach to the Proximal
Humerus ...................................... 102
Approaches to the Distal Humeral
Shaft .......................................... 103
Elbow ........................................... 105
Posterolateral Approach........................ 105
Extensile Posterolateral Approach .......... 108
Posterior Approach by Olecranon
Osteotomy .................................... 108
Extensile Posterior Approach ................ 109
Lateral Approach ............................... 111
Lateral J Approach............................. 112
Medial Approach with an Osteotomy
of the Medial Epicondyle ................. 112
Medial and Lateral Approach ............... 113
Global Approach ............................ 114
Radius .......................................... 115
Posterolateral Approach to the Radial
Head and Neck ............................. 115
Approach to the Proximal and Middle
Thirds of the Posterior Surface .......... 117
Anterior Approach to the Proximal
Shaft and Elbow Joint..................... 117
Anterior Approach to the Distal Half
of the Radius ................................ 117
Ulna.............................................. 117
Approaches to the Proximal Third of
the Ulna and the Proximal Fourth
of the Radius ................................ 117
Wrist ............................................. 122
Dorsal Approaches ............................. 122
Volar Approach ................................. 123
Lateral Approach ............................... 123
Medial Approach ............................... 124

Part I General Principles

SURGICAL TECHNIQUES
This section describes several surgical techniques especially
important in orthopaedics: use of tourniquets, use of radiographs and image intensiers in the operating room, positioning of the patient, local preparation of the patient, and
draping of the appropriate part or parts. To avoid repetition
in other chapters, operative techniques common to many
procedures, xation of tendons or fascia to bone, and bone
grafting also are described.

Tourniquets
Operations on the extremities are made easier by the use
of a tourniquet. The tourniquet is a potentially dangerous
instrument that must be used with proper knowledge and
care. In some procedures, a tourniquet is a luxury, whereas
in others, such as delicate operations on the hand, it is a
necessity. A pneumatic tourniquet is safer than an Esmarch
tourniquet or the Martin sheet rubber bandage.
A pneumatic tourniquet with a hand pump and an
accurate pressure gauge is probably the safest, but a constantly regulated pressure tourniquet is satisfactory if it is
properly maintained and checked. A tourniquet should be
applied by an experienced individual and not delegated to
someone who does not understand its use.
Several sizes of pneumatic tourniquets are available for
the upper and lower extremities. The upper arm or the
thigh is wrapped with several thicknesses of smoothly
applied cotton cast padding. Krackow described a maneuver that improves positioning of the tourniquet in obese
patients. An assistant manually grasps the esh of the
extremity just distal to the level of tourniquet application
and rmly pulls this loose tissue distally before the cast
padding is placed. Traction on the soft tissue is maintained
while the padding and tourniquet are applied and the latter
is secured. The assistants grasp is released, resulting in a
greater proportion of the subcutaneous tissue remaining
distal to the tourniquet. This bulky tissue tends to support
the tourniquet and push it into an even more proximal
position. All air is expressed from the sphygmomanometer
or pneumatic tourniquet before application. When a sphygmomanometer cuff is used, it should be wrapped with a
gauze bandage to prevent its slipping during ination. The
extremity is elevated for 2 minutes, or the blood is expressed
by a sterile sheet rubber bandage or a cotton elastic bandage.
Beginning at the ngertips or toes, the extremity is wrapped
proximally to within 2.5 to 5 cm of the tourniquet. If a
Martin sheet rubber bandage or an elastic bandage is applied
up to the level of the tourniquet, the latter tends to slip
distally at the time of ination. The tourniquet should be
inated quickly to prevent lling of the supercial veins
before the arterial blood ow has been occluded. Every
effort is made to decrease tourniquet time; the extremity

often is prepared and ready before the tourniquet is inated.


Hirota et al., using transesophageal echocardiography
during arthroscopic knee surgery, showed that asymptomatic pulmonary embolism can occur within 1 minute
after tourniquet release. They also found that the number
of small emboli depends on the duration of tourniquet
ination.
The exact pressure to which the tourniquet should be
inated has not been determined. Evidence indicates that
pressures greater than necessary have been used for many
years. The correct pressure depends on the age of the
patient, the blood pressure, and the size of the extremity.
Reid, Camp, and Jacob used pneumatic tourniquet pressures determined by the pressure required to obliterate the
peripheral pulse (limb occlusion pressure) using a Doppler
stethoscope; they added 50 to 75 mm Hg to allow for collateral circulation and blood pressure changes. Tourniquet
pressures of 135 to 255 mm Hg for the upper extremity and
175 to 305 mm Hg for the lower extremity were satisfactory for maintaining hemostasis. Younger et al. showed,
with a prototype automated limb occlusion pressure apparatus, that tourniquet pressures could be reduced by 43%.
This device is now commercially available from Zimmer
Patient Care (Dover, Ohio).
According to Crenshaw et al., wide tourniquet cuffs are
more effective at lower ination pressures than are narrow
ones. Pedowitz et al. showed that curved tourniquets on
conical extremities require signicantly lower arterial
occlusion pressures than straight (rectangular) tourniquets
(Fig. 1-1). The use of straight tourniquets on conical thighs
should be avoided, especially in extremely muscular or
obese individuals.
Any solution applied to skin must not be allowed to run
beneath the tourniquet, or a chemical burn may result. A
circumferential adhesive-backed plastic drape applied to the
skin just distal to the tourniquet prevents solutions from
running under the tourniquet. Sterile pneumatic tourniquets are available for operations around the elbow and
knee. The limb may be prepared and draped before the
tourniquet is applied. Rarely, a supercial slough of the
skin may occur at the upper margin of the tourniquet in
the region of the gluteal fold. This slough usually occurs
in obese individuals and is probably related to the use of a
straight, instead of a curved, tourniquet.
Pneumatic tourniquets should be kept in good repair,
and all valves and gauges must be checked routinely. The
inner tube should be completely enclosed in a casing to
prevent the tube from ballooning through an opening,
allowing the pressure to fall or causing a blowout. The
cuff also should be inspected carefully. On older tourniquets, the rm plastic band that keeps the tourniquet from
rolling must lie supercial to the inatable cuff to prevent
damage to the underlying structures. Damage has been
reported when the plastic band was inserted between the
skin and the inatable cuff.

Chapter 1 Surgical Techniques and Approaches

B
Fig. 1-1 A, Straight (rectangular) tourniquets t optimally
on cylindrical limbs. B, Curved tourniquets best t conical
limbs. (From Pedowitz RA, Gershuni DH, Botte MJ, et al: The
use of lower tourniquet in ation pressures in extremity surgery
facilitated by curved and wide tourniquets and integrated cuff
in ation system, Clin Orthop 287:237, 1993.)

Any aneroid gauge must be calibrated frequently. Newer


gauges carry instruction cards with them. They are sold
with test gauges so that the gauges on the tourniquets can
be tested for proper calibration. The test gauge also is an
aneroid gauge, however, and is subject to error itself. The
test gauge must be tested for accuracy by a mercury
manometer. The test gauge should be checked once a
week, and each tourniquet gauge should be tested with a
test gauge before it is used. If a discrepancy of more than
20 mm between the tourniquet and the test gauge is
present, the equipment should be discarded, and other
equipment that does test properly should be used. One
of the greatest dangers in the use of a tourniquet is an improperly registering gauge; gauges have been found to be
300 mm off calibration. In many tourniquet injuries, the
gauges were later checked and found to be grossly inaccurate, allowing excessive pressure.
Tourniquet paralysis can result from (1) excessive pressure; (2) insufcient pressure, resulting in passive congestion of the part, with hemorrhagic in ltration of the nerve;
(3) keeping the tourniquet on too long; or (4) application
without consideration of the local anatomy. There is no
rule as to how long a tourniquet may be safely inated.
The time may vary with the age of the patient and the

vascular supply of the extremity. In an average healthy


adult younger than 50 years of age, we prefer to leave the
tourniquet inated for no more than 2 hours. If an operation on the lower extremity takes longer than 2 hours, it
is better to nish it as rapidly as possible than to deate
the tourniquet for 10 minutes and then reinate it. It has
been found that 40 minutes is required for the tissues to
return to normal after prolonged use of a tourniquet.
Consequently, the previous practice of deating the tourniquet for 10 minutes seems to be inadequate. Posttourniquet syndrome, as rst recognized by Bunnell, is a
common reaction to prolonged ischemia and is characterized by edema, pallor, joint stiffness, motor weakness, and
subjective numbness. This complication is thought to be
related to the duration of ischemia and not to the mechanical effect of the tourniquet. Sapega et al. have documented
interstitial edema, increased capillary permeability, microvascular congestion, and decreased muscle contractility
after 2 to 3 hours of ischemia. Post-tourniquet syndrome
interferes with early motion and results in increased narcotic requirements. Spontaneous resolution usually occurs
within 1 week.
Compartment syndrome, rhabdomyolysis, and pulmonary emboli are rare complications of tourniquet use.
Vascular complications can occur in patients with severe
arteriosclerosis or prosthetic grafts. A tourniquet should not
be applied over a prosthetic vascular graft.
Pneumatic tourniquets usually are applied to the upper
arm and thigh. In a prospective study, Khuri et al. found
that applying a tourniquet to the forearm is safe and effective for surgery of the hand and wrist. Michelson and Perry
also concluded after a prospective study that a well-padded
proximal calf tourniquet is safe for foot and ankle surgery.
Table 1-1 outlines general guidelines for the safe use of
pneumatic tourniquets.
The Esmarch tourniquet is still in use in some areas and
is the safest and most practical of the elastic tourniquets. It
is never used except in the middle and upper thirds of the
thigh. This tourniquet has a de nite, although limited, use
in that it can be applied higher on the thigh than can the
pneumatic tourniquet. The Esmarch tourniquet is applied
in layers, one on the top of the other; a narrow band produces less tissue damage than does a wide one.
The Esmarch tourniquet should not be applied until the
patient is well anesthetized; otherwise, persistent adductor
muscle spasm may cause the tourniquet to be too loose
after the muscles have relaxed. A hand towel, folded lengthwise in four layers, is wrapped snugly as high as possible
around the upper thigh. The tourniquet is applied over the
towel as follows. The chain end is held over the lateral
surface of the thigh with one hand; the other hand is passed
under the thigh and grasps the rubber strap near the chain
and pulls it taut. The strap is allowed to slip between the
thumb and ngers as the hand is brought under and around
the thigh; properly performed, this slipping produces a

Part I General Principles

Table 1-1 Braithwaite and Klenermans


Modication of Bruners Ten Rules
Application
Size of tourniquet
Site of application
Padding
Skin preparation

Time
Temperature
Documentation
calibration and
maintenance

Apply only to a healthy limb or with


caution to an unhealthy limb
Arm, 10 cm; leg, 15 cm or wider in large
legs
Upper arm; mid/upper thigh ideally
At least two layers of orthopaedic wool
Occlude to prevent soaking of wool. 50
100 mm Hg above systolic for the arm;
double systolic for the thigh; or arm
200250 mm Hg, leg 250350 mm Hg
(large cuffs are recommended for larger
limbs instead of increasing pressure)
Absolute maximum 3 hr (recovers in
57 days) generally not to exceed 2 hr
Avoid heating (e.g., hot lights), cool if
feasible, and keep tissues moist
Duration and pressure at least weekly
against mercury manometer or test
gauge; 3-monthly maintenance

Modied from Kutty S, McElwain JP: Padding under tourniquets in


tourniquet controlled surgery: Bruners ten rules revisited, Injury 33:75,
2002.

singing sound from friction. When it completely encircles


the thigh, the tourniquet is overlapped layer on layer, with
no skin or towel caught between the layers. This is repeated,
keeping constant tension on the strap, until its application
is complete. The hook on the end of the strap is caught in
one of the links of the chain. Care must be taken that
excessive tension is not built up gradually as the tourniquet
is applied.
A Martin rubber sheet bandage can be safely used as a
tourniquet for short procedures on the foot. The leg is
elevated and exsanguinated by wrapping the rubber bandage
up over the malleoli of the ankle and securing it with a
clamp. The distal portion of the bandage is released to
expose the operative area.
Special attention should be given when using tourniquets on ngers and toes. A rubber ring tourniquet or a
tourniquet made from a glove nger that is rolled onto the
digit should not be used because it can be inadvertently left
in place under a dressing, resulting in loss of the digit. A
glove nger or Penrose drain can be looped around the
proximal portion of the digit, stretched, and secured with
a hemostat. This is a much safer method for digital surgery.
It is difcult to include a hemostat inadvertently in a digital
dressing.

Radiographs in the Operating Room


Often it is necessary to obtain radiographs during an orthopaedic procedure. Radiography technicians who work in

the operating room must wear the same clothing and masks
as the circulating personnel. These technicians must have
a clear understanding of aseptic surgical technique and
draping to avoid contaminating the drapes in the operative
eld. Portable radiograph units used in the operating room
should be cleaned regularly and ideally are not used in any
other area of the hospital.
When an unsterile radiograph cassette is to be introduced into the sterile eld, it should be placed inside a
sterile double pillowcase or sterile plastic bag that is folded
over so that the exterior remains sterile. The pillowcase or
plastic bag is covered by a large sterile towel, ensuring at
least two layers of sterile drapes on the cassette. The operative wound should be covered with a sterile towel when
anteroposterior view radiographs are made to avoid possible
contamination from the machine as it is moved into
position.
Portable C-arm image intensier television uoroscopy
allows instantaneous evaluation of the position of fracture
fragments and internal xation devices. Many of these
machines have the ability to make permanent radiographs.
When used near the sterile eld, the C-arm portion of the
machine must be sterilely draped (Fig. 1-2A and B). As
with any electronic device, failure of an image intensier
can occur. In this event, backup plain radiographs are necessary. Two-plane radiographs can be made, even of the
hip when necessary, using portable equipment (Fig. 1-2C
and D). Closed intramedullary nailing or percutaneous
fracture xation techniques may need to be abandoned for
an open technique if the image intensier fails.
All operating room personnel should avoid exposure to
radiographs. Proper lead-lined aprons should be worn
beneath sterile operating gowns. Thyroid shields, leadimpregnated eyeglasses, and rubber gloves are now available to decrease exposure further.

Positioning of the Patient


Before entering the operating room, the surgeon and the
awake, alert patient should agree on the surgical site, and
the surgeon should mark this clearly to prevent a wrongsite error. The position of a patient on the operating table
should be adjusted to afford maximal safety to the patient
and convenience for the surgeon. A free airway must be
maintained at all times, and unnecessary pressure on the
chest or abdomen should be avoided. This is of particular
importance when the patient is prone; in this position,
sandbags are placed beneath the shoulders, and a thin pillow
is placed beneath the symphysis pubis and hips to minimize
pressure on the abdomen and chest. Large, moderately rm
chest rolls extending from the iliac crests to the clavicular
areas may serve the same purpose.
When the patient is supine, the sacrum must be well
padded, and when lying on the side, the greater trochanter
and the bular neck should be similarly protected. When

Chapter 1 Surgical Techniques and Approaches

Fig. 1-2 A and B, Portable C-arm image intensier television uoroscopy setup for fracture
repair. C-arm rotates 90 degrees to obtain lateral view. C and D, Technique for two-plane
radiographs during hip surgery with a portable machine for anteroposterior and lateral views.
Film cassette for lateral view is positioned over superolateral aspect of hip.

a muscle-relaxant drug is used, the danger of stretching a


nerve or a group of nerves is increased. Figure 1-3 shows
traction on the brachial plexus from improper positioning
of the arm. The brachial plexus can be stretched when the
arm is on an arm board, particularly if it is hyperabducted
to make room for the surgeon or an assistant or for administration of intravenous therapy. The arm should never be
tied above the head in abduction and external rotation
while a body cast is applied because this position may cause
a brachial plexus paralysis. Rather, the arm should be suspended in exion from an overhead frame, and the position
should be changed frequently. Figure 1-4 shows the position of the arm on the operating table that may cause
pressure on the ulnar nerve, particularly if someone on the
operating team leans against the arm. The arm must never
be allowed to hang over the edge of the table. Padding

should be placed over the area where a nerve may be


pressed against the bone (i.e., the radial nerve in the arm,
the ulnar nerve at the elbow, and the peroneal nerve at the
neck of the bula).

Local Preparation of the Patient


Supercial oil and skin debris are removed with a thorough
10-minute soap-and-water scrub. We prefer a skin cleanser
containing 7.5% povidone-iodine solution that is diluted
approximately 50% with sterile saline solution.
Hexachlorophene-containing skin cleanser is substituted
when allergy to shell sh or iodine is present or suspected.
After scrubbing, the skin is blotted dry with sterile towels.
This scrub can be performed in the patients room just
before surgery or in the operating room. If performed

Part I General Principles

Scalenus medius
muscle
Brachial plexus

Scalenus anterior
muscle
Clavicle

1st rib
Humerus

Axillary artery
Pectoralis minor
muscle

Fig. 1-3 Anatomical relationships of brachial plexus when limb is hyperabducted. Inset, With
patient in Trendelenburg position, brace at shoulder is in poor position because limb has been
abducted and placed on arm board.

outside the operating room, the extremity must be wrapped


securely with sterile sheets.
After a tourniquet has been put on, if one is required,
the sterile dressings applied during the earlier preparation
should be removed. Care should be taken that the operative
eld does not become contaminated because the effectiveness of the preparation would be partially lost. With the
patient in the proper position, the solutions are applied,
each with a separate sterile sponge stick, beginning in the
central area of the site of the incision and proceeding

peripherally. Tincture of iodine containing 85% alcohol is


still widely used as a skin preparation. Once painted on, it
is allowed to dry and then is taken off with plain alcohol.
Some surgeons routinely use povidone-iodine solution,
especially when the risk of a chemical burn from tincture
of iodine is signicant. The immediate operative eld is
prepared rst; the area is enlarged to include ample surrounding skin. The sponges used to prepare the lumbar
spine are carried toward the gluteal cleft and anus rather
than in the opposite direction. Sponges should not be satu-

Humerus
Median
nerve
Radial
nerve

Ulnar
nerve
Medial epicondyle

Fig. 1-4 Points at which nerves of arm may be damaged by pressure. Inset, Pressure is applied
to medial side of arm because patient is poorly positioned on operating table.

Chapter 1 Surgical Techniques and Approaches

rated because the solution would extend beyond the operative eld and must be removed. Excessive iodine, even in
the operative eld, should be removed with alcohol to
prevent chemical dermatitis. If the linen on the table or
the sterile drapes become saturated with strong antiseptic
solutions, they should be replaced by fresh linen or drapes.
Solutions should not be allowed to ow underneath a
tourniquet.
If a patient is allergic to iodine, plain alcohol can be
used as a skin preparation. Colored proprietary antiseptics,
commonly used in abdominal surgery, are not suitable in
surgery of the extremities when preparation of the toes or
ngernails is involved. Most of these solutions are difcult
to remove, and the residual red, pink, or orange color
makes evaluation of the circulation difcult after surgery.
When traumatic wounds are present, tincture of iodine
and other alcohol-containing solutions should not be used
for antiseptic wound preparation. Povidone-iodine or hexachlorophene solutions without alcohol should be used
instead to avoid tissue death.
In operations around the upper third of the thigh, the
pelvis, or the lower lumbar spine in male patients, the
genitals should be displaced and held away from the operative eld with adhesive tape. A long, wide strip of tape
similarly helps cover the gluteal cleft, a potential source of
infection. In female patients, the genital area and gluteal
cleft also are covered longitudinally by strips of adhesive
tape. Adherent, sterile, plastic drapes can be used for these
purposes.
Before the operative eld in the region of the lower
lumbar spine, sacroiliac joints, or buttocks is prepared, the
gluteal cleft is sponged with alcohol, and sterile dry gauze
is inserted around the anus so that iodine or other solutions
are prevented from running down to this region, causing
dermatitis.
Brown et al. and others recommend that before total
joint arthroplasty, the extremity should be held by a
scrubbed and gowned assistant, because this reduces bacterial air counts by almost half. They also recommend that
instrument packs not be opened until skin preparation and
draping are completed.
When these preparations are done in haste, the gown
or gloves of the sterile assistant preparing the area may
become contaminated without the assistants knowledge.
To prevent this, a nurse or anesthetist should be appointed
to watch this stage of preparation.
Wound Irrigating Solutions
At my institution, we routinely irrigate clean surgical
wounds to keep them moist with sterile isotonic saline or
lactated Ringer solution. Occasionally, if the risk of wound
contamination is high, antimicrobial irrigating solutions
are used. Dirschl and Wilson recommend a triple antibiotic
solution of bacitracin, neomycin, and polymyxin, because
it provides the most complete coverage in clean and

contaminated wounds. Antibiotic solutions should remain


in the wound for at least 1 minute. Pulsatile lavage systems
are more effective in wound irrigation than are simple
basting-type syringes.

Draping
Draping is an important step in any surgical procedure and
should not be assigned to an inexperienced assistant.
Haphazard draping that results in exposure of unprepared
areas of skin in the middle of an operation can be catastrophic. Considerable experience is required in placing the
drapes, not only to prevent their becoming disarranged
during the operation but also to avoid contamination of
the surgeon and the drapes. If there is the least doubt as to
the sterility of the drapes or the surgeon when draping is
complete, the entire process should be repeated. Unless
assistants are well trained, the surgeon should drape the
patient.
In the foundation layer of drapes, towel clips or skin
staples are placed not only through the drapes but also
through the skin to prevent slipping of the drapes and
exposure of the contaminated skin. In every case, the
foundation drapes should be placed to overlap the prepared
area of skin at least 3 inches (7.5 cm). During draping, the
gloved hands should not come in contact with the prepared
skin.
Cloth drapes are being replaced with disposable paper
and plastic drape packages specically designed for the area
to be draped (Figs. 1-5 and 1-6). A disposable drape package
should have at least one layer made of waterproof plastic
to prevent uids from soaking through to unprepared areas
of the body. Drape packages for bilateral knee and foot
surgery also are available. Paper drapes give off lint that
collects on exposed horizontal surfaces in the operating
room if those surfaces are not cleaned daily.

Fig. 1-5

Disposable drape package for knee surgery.

10

Fig. 1-6

Part I General Principles

Disposable drape package for hip surgery.

Draping the Edges of the Incision


The gloved hand should not come in contact with the skin
before the incision is made. For the extremities, a section
of sterile stockinette is drawn proximally over the operative
eld. The stockinette is grasped proximally and distally and
cut with scissors to uncover the area of the proposed incision. Its cut edges are pulled apart, and the area is covered
by a transparent adhesive-coated material (Fig. 1-7). A
large transparent plastic adhesive drape may be wrapped
entirely around the extremity or over the entire operative
eld so that the stockinette is not needed. The incision is
made through the material and the skin at the same time.
The edges of the incision are neatly draped, and the operative eld is virtually waterproof; this prevents the drapes
in some areas from becoming soaked with blood, which
can be a source of contamination. The plastic adhesive
drape minimizes the need for towel clips or staples around
the wound edge and allows the entire undraped eld to be
seen easily. This visibility is especially important when
there are scars from previous injuries or surgery that must
be accommodated by a new incision.

Prevention of Human Immunodeciency


Virus Transmission
At my institution, we agree with the American Academy
of Orthopaedic Surgeons (AAOS) Task Force recommendations on acquired immunodeciency syndrome (AIDS),
which go beyond those recommended for health care personnel by the Centers for Disease Control and Prevention
and the American Hospital Association. Every effort should
be made to prevent further transmission of human immunodeciency virus HIV/AIDS in all areas of medical care.
For specic recommendations, the reader is referred to the
AAOS Task Force guidelines. We strongly agree with the

Fig. 1-7

Iodoform-impregnated plastic adhesive drape.

following AAOS recommendations regarding HIV precautions in the operating room:


1. Do not hurry an operation. Excess speed results in
injury. The most experienced surgeon should be responsible for the surgical procedure if the risk of injury to
operating room personnel is high.
2. Wear surgical garb that offers protection against contact
with blood. Knee-high, waterproof, surgical shoe covers,
water-impervious gowns or undergarments, and full
head covers should be worn.
3. Double gloves should be worn at all times.
4. Surgical masks should be changed if they become moist
or splattered.
5. Protective eyewear (goggles or full face shields) that
covers exposed skin and mucous membranes should be
used.
6. To avoid inadvertent injury to surgical personnel, the
surgeon should:
Use instrument ties and other no-touch suturing
and sharp instrument techniques when possible.
Avoid tying with a suture needle in hand.
Avoid passing sharp instruments and needles from
hand to hand; instead they should be placed on an
intermediate tray.
Announce when sharp instruments are about to be
passed.
Avoid having two surgeons suture the same wound.
Take extra care when performing digital examinations
of fracture fragments or wounds containing wires or
sharp instrumentation.
Avoid contact with osteotomes, drill bits, and saws.
Use space suittype garb when splatter is inevitable,
such as when irrigating large wounds or using power
equipment.

Chapter 1 Surgical Techniques and Approaches

Routinely check gowns, masks, and shoe covers of


operating room personnel for contamination during
the surgical procedure and change as necessary.

Special Operative Techniques


Special operative techniques are used in a variety of procedures and are described here so that repetition in other
chapters will be unnecessary. The methods of tendon or
fascia xation and bone grafting are discussed here. The
methods of tendon suture are discussed in Chapter 63.
Fixation of Tendon to Bone
The principles of tendon suture are described in Chapter
63 on the hand; in Chapter 46, in which disorders of
muscles and tendons are discussed; and under the discussion
of tendon transfers in Chapter 68. The following discussion
deals only with the methods of attaching a tendon to
bone.
In the xation of a tendon to bone, the apposing surfaces of bone and tendon should be scaried to hasten
attachment. The periosteum must be incised and elevated
enough to expose the bony surface and permit scarication.
After completion of the tendon xation, an attempt should
be made to close the periosteum over the tendon, although
this usually is impossible. Instead, the periosteum may be
sutured to the edges of the tendon.
The simplest method of tendon xation consists of
placing a suture in the end of the tendon by one of the
techniques described in Chapter 63. With this suture, the
tendon is pulled distally, all slack is removed, and the point
of its attachment is determined. Just distal to this point, a
hole is drilled transversely into the bone. The sutures on
each side of the tendon are passed through this hole in
opposite directions and tied tightly over the shaft of the
bone (Fig. 1-8A). If the tendon is long enough, the end is
passed through the hole in the bone and sutured to itself
(Fig. 1-8B).

11

Passing a tendon or a piece of fascia through a hole


drilled in bone often is difcult because inserting the material into the bone at the point of entry is difcult or
because the tendon or fascia becomes caught inside the
tunnel. Krackow and Cohn devised a technique that provides traction to and constriction of the tendon or fascia
and decreases the difculties of pulling the tissue into and
through a tunnel (Fig. 1-9). A homemade Chinese nger
trap is constructed from two pieces of suture woven around
the tendon. If a distally based strip of iliotibial band is to
be inserted into bone, the part of the band that is to be
inserted is rolled into a cylindrical shape, and a suitable
length of strong, nonabsorbable suture is wrapped around

A
Fig. 1-8

AC, Fixation of tendon to bone.

Fig. 1-9 Krackow and Cohn technique for passing tendon


or fascia through hole in bone. A, Suture is wrapped in
crisscross fashion around the distal end of the tendon or
fascia and is tied in a knot, leaving the ends of the suture
long. B, A second suture is wrapped in similar fashion, but
out of phase with the rst suture. C, A Chinese nger-trap
suture ts tightly around the tendon or fascia and allows it
to enter the hole without difculty. (Redrawn from Krackow
KA, Cohn BT: A new technique for passing tendon through
bone: brief note, J Bone Joint Surg 69A:922, 1987.)

12

Part I General Principles

the fascia in a crisscross fashion, beginning about 4 cm


proximal to the end of the strip. At the end of the strip,
the suture is tied into a knot, leaving the ends long (Fig.
1-9A). A second piece of suture is wrapped around the
fascia in the same way but out of phase with the rst piece
of suture (Fig. 1-9B). This suture also is tied at the end.
The ends of the suture are passed through the hole in the
bone (Fig. 1-9C), followed by the rolled up fascial strip.
Finally, the sutures are cut just proximal to the knots at
the apex of the nger trap and are easily removed, one at
a time.
A broad, rm, bony attachment must be ensured for the
larger muscles; it may be obtained by the method shown
in Figure 1-8C. The advantage of this method is that drilling a transverse hole through the shaft of the bone is
unnecessary; such a procedure is sometimes difcult in
deep wounds, and exposure requires considerable stripping
of soft tissues from the bone. The method of xing a
tendon in the medullary canal is as follows. After placing
the suture in the end of the tendon and leaving two long,
free strands, a trapdoor is made in the bone, exposing the
medullary canal at the predetermined point of attachment.
Just distal to the trapdoor, two holes are drilled through
the cortex into the medullary canal. The free ends of the
suture are passed through the trapdoor and out through the
two holes. When these sutures are pulled taut, the end of
the tendon is drawn through the trapdoor into the medullary canal. The trapdoor may be partially replaced or
broken into small fragments and packed into the defect as
grafts.
Krackow, Thomas, and Jones have devised a locking
loop suture that is relatively simple to use and is especially

suited to attaching at structures, such as the tibial collateral ligament, joint capsule, or patellar tendon to bone. It
allows the application of tension to the structure, resists
pulling out, and does not cause major purse-stringing or
bunching. When used with strong suture material, a
doubled suture was found by the author to be nearly twice
as strong as stable xation to bone. When the suture is used
in combination with a staple, xation is signicantly
improved. Figure 1-10 illustrates the technique used to
create the xation suture. The tendon or ligament is
approached from the raw end, and three or more locking
loops are placed along each side of the structure. Tension
is applied during the procedure to remove excess suture
material within the locking loops. This suture may be
reinforced proximal to the rst suture. The tendon or ligament and the suture are attached to bone through holes
drilled in the bone, or the suture is tied over a screw or
staple xed in the bone.
Because of the scarcity of surrounding soft tissue and
the nature of the bone, Coles method is especially applicable to the xation of tendons to the dorsum of the tarsus,
to the calcaneus, or to the phalanges of the ngers (Fig.
1-11). The tendon is prepared, and a pull-out suture is
placed in the end of the tendon, as described for end-toend sutures (see Chapter 63). A small ap of bone is
reected with a chisel, and at the apex of the ap a tunnel
is drilled through the bone. Both ends of the wire suture
are placed on a long, straight skin needle. The needle is
passed through the hole in the bone and out through the
skin on the opposite side, drawing the end of the tendon
into the tunnel. The wire is snugly anchored over a loop
of gauze or a padded button. If considerable tension is

Fig. 1-10 Krackow, Thomas, and Jones


technique for ligament or tendon xation to bone. AG, Detail of placement
of suture in wide tendon. (Redrawn
from Krackow KA, Thomas SC, Jones
LC: Ligament-tendon xation: analysis
of a new stitch and comparison with
standard techniques, Orthopedics 11:909,
1988.)

13

Chapter 1 Surgical Techniques and Approaches

A
The Cole method of anchoring tendons to bone.
Ends of wire suture are passed on a straight skin needle
through a hole drilled in bone. The needle is drawn through
the skin on the opposite side. Wire sutures are anchored
over rubber tube or button. To prevent necrosis of the skin
when the suture is under considerable tension, ends of wire
may be passed through the bottom of the cast. Subsequently,
wire is anchored over the button on the outside of cast.
Fig. 1-11

Fig. 1-12 Suture-anchoring implants. A, Statak (Zimmer)


suture-anchoring device is drilled into bone. B, QuickAnchor
(Mitek) suture anchor consists of a hook device with suture
that is anchored into drill hole in the bone.

Fixation of the Osseous Attachment of Tendon


to Bone
When larger muscles are transferred, such as the quadriceps
or the abductor muscles of the hip, better xation is secured
if the tendon is removed with a portion of its bony attachment. Sufcient bone is removed to ensure a cancellous
surface. The bony segment is drawn distally, and the location of its reattachment is determined. At this point, the
periosteum is elevated, the surface of the shaft is scaried,

> 10 mm

necessary, as in Achilles tendon, the skin should be


padded with heavy felt. A cast is applied with the wires
protruding through the bottom of the cast. After the plaster
sets, the wire is anchored over a button on the outside of
the cast.
Suture-anchoring devices also are useful in securing
tendon, ligament, or capsule to bone (Fig. 1-12). The pullout strength of these devices is at least equal to that of a
suture passed through drill holes in bone, and these devices
are especially useful in deep wounds with limited room,
such as in the shoulder. Tingart et al. found that metal
suture anchors withstand a signicantly higher load to
failure than biodegradable anchors. Suture anchors made
from methylmethacrylate cement are useful in osteopenic
bone (Fig. 1-13).
A tendon or ligament also can be secured to bone
through a drill hole using a screw for an interference t as
in anterior cruciate ligament reconstruction procedures (see
Chapter 43). Allograft cortical bone is now being commercially machined into screws for such a purpose.

> 3 mm
Fig. 1-13 Methylmethacrylate suture anchor. Figure-of-eight
knot increases load to failure. (From Meyer DC, Jacob HAC,
Pistoia W, et al: The use of acrylic bone cement for suture
anchoring, Clin Orthop 410:295, 2003.)

14

Part I General Principles

Fig. 1-14 Fixation of osseous attachment of tendon to bone.


A, Fixation by screw or threaded pins. B, Fixation by mattress suture of wire through holes drilled in bone. C, Fixation
by wire loops.

Bone Grafting
The principles, indications, and techniques of bone grafting
procedures were well established before the metallurgic
age of orthopaedic surgery. Because of the necessity of
using autogenous materials such as bone pegs or, in some
cases, wire loops, xation of grafts was crude. Lane and
Sandhu introduced internal xation; Albee and Kushner,
Henderson, Campbell, and others added osteogenesis to
this principle to develop bone grafting for nonunion into
a practical procedure. The two principles, xation and
osteogenesis, were not efciently and simply combined,
however, until surgeons began osseous xation with inert
metal screws, after which came the bone bank with its
obvious advantages. Much clinical and experimental work
is being done to improve the safety and results of bone
grafting: Donors are being more carefully selected to
prevent the transmission of HIV and other diseases; tissue
typing and the use of immunosuppressants are being tried;
autologous bone marrow is being added to autogenous and
homogeneous bone grafts to stimulate osteogenesis; and
bone graft substitutes have been developed.
Indications

and the attachment of the tendon is xed to the raw area


by two threaded pins inserted obliquely or by a screw
(Fig. 1-14A). Stone and du Toit staples also are useful for
anchoring a ligament or a tendon to bone (Figs. 1-15 and
1-16). Wire loops passed through holes drilled into the
bone (see Fig. 1-14B and C) are efcient. Silk, polyester,
or chromic catgut No. 2 sutures may be used instead of
metal for xation of tendons in the less powerful muscles.
If desired, a trapdoor may be made in the shaft of the bone,
and the osseous attachment of the tendon can be countersunk into the defect and held by a suture, as illustrated in
Figure 1-8.

Stone staple, used most frequently for anchoring


tendinous tissue to bone.
Fig. 1-15

Bone grafts may be used for the following

purposes:
1. To ll cavities or defects resulting from cysts, tumors,
or other causes
2. To bridge joints and provide arthrodesis
3. To bridge major defects or establish the continuity of a
long bone
4. To provide bone blocks to limit joint motion
(arthroereisis)
5. To establish union in a pseudarthrosis
6. To promote union or ll defects in delayed union,
malunion, fresh fractures, or osteotomies

Fig. 1-16 Modied du Toit staples. Barbs make extrusion of


staple less likely. Several widths and lengths of staples are
available.

Chapter 1 Surgical Techniques and Approaches

Cortical bone grafts are used primarily for structural support, and cancellous bone grafts are
used for osteogenesis. Structural support and osteogenesis
may be combined; this is one of the prime advantages of
using bone graft. These two factors vary, however, with
the structure of the bone. Probably all or most of the cellular elements in grafts (particularly cortical grafts) die and
are slowly replaced by creeping substitution, the graft
merely acting as a scaffold for the formation of new bone.
In hard cortical bone, this process of replacement is
considerably slower than in spongy or cancellous bone.
Although cancellous bone is more osteogenic, it is not
strong enough to provide efcient structural support. When
selecting the graft or combination of grafts, the surgeon
must be aware of these two fundamental differences in
bone structure. When a graft has united with the host and
is strong enough to permit unprotected use of the part,
remodeling of the bone structure takes place commensurate
with functional demands.
Structure of Grafts

Source of Grafts

Autogenous Grafts
When the bone grafts come from the patient, the grafts
usually are removed from the tibia, bula, or ilium. These
three bones provide cortical grafts, whole bone transplants,
and cancellous bone. Rarely is a resected rib appropriate.
When internal or external xation appliances are not
used, which is currently rare, strength is necessary in a graft
used for bridging a defect in a long bone or even for the
treatment of pseudarthrosis. The subcutaneous anteromedial aspect of the tibia is an excellent source for such grafts.
In adults, after removal of a cortical graft, the plateau of
the tibia supplies cancellous bone. Apparently, leaving the
periosteum attached to the graft has no advantage; however,
suturing to the periosteum over the defect has denite
advantages. The periosteum seems to serve as a limiting
membrane to prevent irregular callus when the defect in
the tibia lls in with new bone. The few bone cells that
are stripped off with the periosteum can help in the formation of bone needed to ll the defect.
Disadvantages to the use of the tibia as a donor area
include the following: (1) a normal limb is jeopardized; (2)
removal of the graft adds to the duration and magnitude
of the procedure; (3) convalescence is prolonged, and
ambulation must be delayed until the defect in the tibia
has partially healed; and (4) the tibia must be protected for
6 to 12 months to prevent fractures. For these reasons,
structural autografts from the tibia are now rarely used.
The entire proximal two thirds of the bula can be
removed without disabling the leg. A study by Gore et al.
indicates, however, that most patients have complaints and
mild muscular weakness after removal of a portion of the
bula. The conguration of the proximal end of the bula
is an advantage. The proximal end has a rounded prominence that is partially covered by hyaline cartilage and

15

forms a satisfactory transplant to replace the distal third of


the radius or the distal third of the bula. After transplantation, the hyaline cartilage probably degenerates rapidly into
a brocartilaginous surface; even so, this surface is preferable to raw bone.
The middle one third of the bula also can be used as
a vascularized free autograft based on the peroneal artery
and vein pedicle using microvascular technique. Simonis,
Shirall, and Mayou recommend this graft for the treatment
of large defects in congenital pseudarthrosis of the tibia
(see Chapter 26). Portions of iliac crest also can be used as
free vascularized autograft. The use of free vascularized
autografts has limited indications, requires expert microvascular technique, and is not without donor site
morbidity.
Allogenic Grafts
An allogenic graft, or allograft, is one that is obtained from
an individual other than the patient. Before the development of the bone bank (see discussion that follows),
allografts were used only when autogenous grafts were
unavailable or when there were objections to their use. In
small children, the usual donor sites do not provide cortical
grafts large enough to bridge defects, or the available cancellous bone may not be enough to ll a large cavity or
cyst; the possibility of injuring a physis also must be considered. Grafts for small children usually were removed
from the father or mother. Larger structural allografts have
been used successfully for many years in revision total joint
surgery, periprosthetic long bone fractures, and reconstruction after tumor excision. Osteochondral allografts are now
being used with some success in a few centers to treat distal
femoral osteonecrosis. Table 1-2 summarizes the various
properties of autogenous and allogenic bone grafts.
Heterogeneous Grafts
Because of the undesirable features of autogenous and allogenic bone grafting, heterogeneous bone, that is, bone
from another species, was tried early in the development
of bone grafting and was almost always found to be unsatisfactory. The material more or less retained its original
form, acting as an internal splint, but not stimulating bone
production. These grafts often incited an undesirable
foreign body reaction. Consistently satisfactory heterogeneous graft material still is not commercially available, and
its use is not recommended.
Opinions differ among orthopaedic surgeons
regarding the use of preserved allogenic bone, although its
practical advantages are many. Fresh autogenous bone generally must be obtained through a second incision, which
adds to the size and length of the operation and to the
blood loss. After removal of a cortical graft from the tibia,
the leg must be protected to prevent fracture at the donor
site. At times it is not possible to obtain enough autogenous
bone to meet the needs of the operation.
Bone Bank

16

Part I General Principles

Table 1-2 Properties of Autografts and Allografts


Bone Graft

Structural Strength

Osteoconduction

Osteoinduction

Osteogenesis

Autograft
Cancellous
Cortical

No
+++

+++
++

+++
++

+++
++

No
No

++
++

+
+

No
No

+++
+

+
+

No
No

No
No

Allograft
Cancellous
Frozen
Freeze-dry
Cortical
Frozen
Freeze-dry

From The Committee on Biological Implants: Bone-graft substitutes: facts, ctions, and applications, J Bone Joint Surg 83A:99, 2001.

If osteogenesis is the prime concern, fresh autogenous


bone is the best graft. Autogenous bone is preferable when
grafting nonunions of fractures of the long bones. If stability is not required of a graft, cancellous autogenous iliac
grafts are superior to autogenous grafts from the tibia.
Allografts are indicated in small children, the elderly,
patients who are poor operative risks, and patients from
whom not enough acceptable autogenous bone is available.
Autogenous cancellous bone can be mixed in small amounts
with allograft bone as seed to provide osteogenic potential. Mixed bone grafts of this type incorporate more
rapidly than allograft bone alone.
To provide safe and useful allograft material efciently,
a bone banking system is required that uses thorough donor
screening, rapid procurement, and safe, sterile processing.
Standards outlined by the American Association of Tissue
Banks must be followed. Donors must be screened for
bacterial, viral (including HIV and hepatitis), and fungal
infections. Malignancy (except basal cell carcinoma of the
skin), collagen vascular disease, metabolic bone disease,
and the presence of toxins are all contraindications to
donation.
Bone and ligament and bone and tendon are now banked
for use as allografts. The use of allograft ligaments and
tendons in knee surgery is discussed in Chapter 46. Bone
can be stored and sterilized in several forms. It can be
harvested in a clean, nonsterile environment; sterilized by
irradiation, strong acid, or ethylene oxide; and freeze-dried
for storage. Bone under sterile conditions can be deep
frozen (70C to 80C) for storage. Fresh frozen bone is
stronger than freeze-dried bone and better as structural
allograft material. Articular cartilage also can be cryopreserved in this manner. Cancellous allografts incorporate to
host bone, as do autogenous cancellous grafts. These
allografts are mineralized and are not osteoinductive,
although they are osteoconductive. Cancellous allografts
can be obtained in a demineralized form that increases

osteogenic potential, but greatly decreases resistance to


compressive forces.
Enneking and Mindell observed that cortical allografts
are invaded by host blood vessels and substituted
slowly with new host bone to a limited degree, especially in massive allografts. This probably accounts for
the high incidence of fracture in these grafts, because
dead bone cannot remodel in response to cyclic loading
and fails.
Cancellous Bone Substitutes Interest in bone graft substitutes has mushroomed in recent years. A dozen products
are in general use or in clinical trials. To understand better
the properties of these products, the following bone synthesis processes need to be understood. Graft osteogenesis is
the ability of cellular elements within a graft that survive
transplantation to synthesize new bone. Graft osteoinduction
is the ability of a graft to recruit host mesenchymal stem
cells into the graft that differentiate into osteoblasts. Bone
morphogenetic proteins and other growth factors in the
graft facilitate this process. Graft osteoconduction is the ability
of a graft to facilitate blood vessel ingrowth and bone formation into a scaffold structure.
Bone graft substitutes can replace autologous or allogenic grafts or expand an existing amount of available graft
material. Autologous cancellous and cortical grafts are still
the gold standards against which all other graft forms are
judged. Bone graft substitutes are classied based on properties outlined in Table 1-3. Widely used bone graft substitutes are compared in Table 1-4.

Indications for Various Techniques

Single Onlay Cortical Grafts


Until relatively inert metals became available, the onlay
bone graft (see Chapter 56) was the simplest and most
effective treatment for most ununited diaphyseal fractures.

Chapter 1 Surgical Techniques and Approaches

17

Table 1-3 Classication of Bone Graft Substitutes


Property

Description

Classes

Osteoconduction

Provides a passive porous scaffold to support


or direct bone formation
Induces differentiation of stem cells into
osteogenic cells
Provides stem cells with osteogenic potential,
which directly lays down new bone
Provides more than one of the above
mentioned properties

Calcium sulfate, ceramics, calcium phosphate cements,


collagen, bioactive glass, synthetic polymers
Demineralized bone matrix, bone morphogenic proteins,
growth factors, gene therapy
Bone marrow aspirate

Osteoinduction
Osteogenesis
Combined

Composites

From Parikh SN: Bone graft substitutes in modern orthopedics, Orthopedics 25:1301, 2002.

Usually the cortical graft was supplemented by cancellous


bone for osteogenesis. The onlay graft is still applicable to
a limited group of fresh, malunited, and ununited fractures
as well as after osteotomies.
Cortical grafts also are used when bridging joints to
produce arthrodesis, not only for osteogenesis but also for
xation. Fixation as a rule is best furnished by internal or
external metallic devices. Only in an extremely unusual
situation would a cortical onlay graft be indicated for xation, and then only in small bones and when little stress is
expected. For osteogenesis, the thick cortical graft has
largely been replaced by thin cortical and cancellous bone
from the ilium.

Dual Onlay Grafts


Dual onlay bone grafts are useful when treating difcult
and unusual nonunions or for bridging massive defects
(see Chapter 56). The treatment of a nonunion near a
joint is difcult because the fragment nearest the joint is
usually small, osteoporotic, and largely cancellous, having
only a thin cortex. It is often so small and soft that xation
with a single graft is impossible because screws tend to pull
out of it and wire sutures cut through it. Dual grafts
provide stability because they grip the small fragment like
forceps. Nonunion of shaft fractures in elderly patients
whose bones are osteoporotic also should be treated with
dual grafts.

Table 1-4 Characteristics of Commercially Available Bone Graft Substitutes


Commercially
Available
Product

OrthoBlast

DynaGraft

ProOsteon 500R

Grafton

OSTEOSET

Allomatrix

Collagraft

Composition

Heat-sensitive
copolymer
with
cancellous
bone chips
and DBM

Heat-sensitive
copolymer
with DBM

Coral
hydroxyapatite
composite

DBM combined
with glycerol

Surgical-grade
calcium sulfate

DBM with
surgical-grade
calcium sulfate
powder

Mixture of
hydroxyapatite,
tricalcium
phosphate,
and bovine
collagen

Commercially
Available
Forms

Injectable paste
or putty

Injectable gel,
matrix, or
putty

Granular or
block

Gel

Various sized
pellets

Injectable or
formable putty

Strip
congurations

Claimed
Mechanisms
of Action

Osteoconduction;
bioresorbable;
limited
osteoinduction

Osteoconduction;
bioresorbable;
limited
osteoinduction

Osteoconduction;
bioresorbable

Osteoconduction;
bioresorbable;
limited
osteoinduction

Osteoconduction;
bioresorbable

Osteoconduction;
bioresorbable;
limited
osteoinduction

Osteoconduction;
bioresorbable;
limited
osteoinduction
when mixed
with bone
marrow

Burdens of
Proof

Case reports;
animal studies;
cell culture

Human studies;
case reports;
animal studies;
cell culture

Human studies;
case reports;
animal studies

Human studies;
case reports;
animal studies

Human studies;
case reports;
animal studies

Case reports;
animal studies;
cell culture

Human studies;
case reports;
animal studies;
cell culture

FDA Status

Minimal
manipulation;
nonregulated

Minimal
manipulation;
nonregulated

Approved
510K

Minimal
manipulation;
nonregulated

Approved 510K

Minimal
manipulation;
nonregulated

Approved
PMA

510K, premarketing notication submissions; DBM, demineralized bone matrix; FDA, Food and Drug Administration; PMA, premarket approval.
From The Committee on Biological Implants: Bone-graft substitutes: facts, ctions, and applications, J Bone Joint Surg 83A:99, 2001.

18

Part I General Principles

The advantages of dual grafts for bridging defects are as


follows: (1) Mechanical xation is better than xation by a
single onlay bone graft; (2) the two grafts add strength and
stability; (3) the grafts form a trough into which cancellous
bone may be packed; and (4) during healing, the dual grafts,
in contrast to a single graft, prevent contracting brous
tissue from compromising transplanted cancellous bone.
After a large defect in the lower extremity is bridged by dual
grafts, protection from full weight bearing is necessary for
a long time. Consequently, if shortening would not be too
great, the defect should be obliterated, and the fragments
should be apposed before the grafts are applied. A whole
bular graft usually is better than dual grafts for bridging
defects in the upper extremity except when the bone is
osteoporotic or when the nonunion is near a joint.
The disadvantages of dual grafts are the same as those
of single cortical grafts: (1) they are not as strong as metallic xation devices; (2) an extremity usually must serve as
a donor site if autogenous grafts are used; and (3) they are
not as osteogenic as autogenous iliac grafts, and the surgery
necessary to obtain them has more risk.
Inlay Grafts
By the inlay technique, a slot or rectangular defect is
created in the cortex of the host bone (see Chapter 56),
usually with a power saw. A graft the same size or slightly
smaller is tted into the defect. In the treatment of diaphyseal nonunions, the onlay technique is simpler and more
efcient and has almost replaced the inlay graft. The latter
still is occasionally used in arthrodesis, particularly at the
ankle (see Chapter 3).
Peg Grafts
Peg grafts usually are considered an innocuous means of
internal xation rather than a means of osteogenesis.
Because they are weaker than metal, their use is limited to
conditions such as nonunions of the medial malleolus and
some of the small bones of the hand, wrist, or foot.
Medullary Grafts
Medullary bone grafts were tried early in the development
of bone grafting techniques for nonunion of diaphyseal
fractures. Fixation was insecure, and healing was rarely
satisfactory. This graft interferes with endosteal circulation
and consequently can interfere with healing. Medullary
grafts are rarely used except in the metatarsals, the metacarpals, and the distal end of the radius.
Osteoperiosteal Grafts
Osteoperiosteal grafts are less osteogenic than multiple cancellous grafts and are now rarely used.
Multiple Cancellous Chip Grafts
Multiple chips of cancellous bone are widely used for grafting. Segments of cancellous bone are the best osteogenic
material available. They are particularly useful for lling
cavities or defects resulting from cysts, tumors, or other

causes; for establishing bone blocks; and for wedging in


osteotomies. Being soft and friable, this bone can be packed
into any nook or crevice. The ilium is a good source of
cancellous bone, and if some rigidity and strength are
desired, the cortical elements may be retained. In most
bone grafting procedures that use cortical bone or metallic
devices for xation, supplementary cancellous bone chips
or strips are used to hasten healing. Cancellous grafts are
particularly applicable to arthrodesis of the spine because
osteogenesis is the prime concern.
Hemicylindrical Grafts
Hemicylindrical grafts are suitable for obliterating large
defects of the tibia and femur. A massive hemicylindrical
cortical graft from the affected bone is placed across the
defect and is supplemented by cancellous iliac bone. A
procedure of this magnitude has only limited use, but it is
applicable for resection of bone tumors when amputation
is to be avoided.
Whole Bone Transplant
The bula provides the most practical graft for bridging
long defects in the diaphyseal portion of bones of the
upper extremity, unless the nonunion is near a joint. A
bular graft is stronger than a full-thickness tibial graft.
When soft tissue is scant, a wound that cannot be closed
over dual grafts can be closed over a bular graft. Disability
after removing a bular graft is less than after removing a
larger tibial graft. In children, the bula can be used to
span a long gap in the tibia, usually by a two-stage procedure (see Chapter 56). The shape of the proximal
end of the bula makes it a satisfactory substitute for the
distal end of the bula or distal end of the radius (see
Chapter 19).
A free vascularized bular autograft has greater osteogenic potential for incorporation but is technically much
more demanding. Bone transplants consisting of whole
segments of the tibia or femur, usually freeze-dried or fresh
frozen, are available. Their greatest use is in the treatment
of defects of the long bones produced by massive resections
for bone tumors or complex total joint revisions (see
Chapter 19).
The conditions
favorable for bone grafting are discussed in Chapter 56.
Conditions Favorable for Bone Grafting

Preparation of Grafts

Removal of a Tibial Graft


TECHNIQUE 1-1
To avoid excessive loss of blood, use a tourniquet (preferably
pneumatic) when the tibial graft is removed. After removal of
the graft, the tourniquet may be released without disturbing the
sterile drapes.

Chapter 1 Surgical Techniques and Approaches

Make a slightly curved longitudinal incision over the


anteromedial surface of the tibia, placing it so as to prevent a
painful scar over the crest.
Without reecting the skin, incise the periosteum to the bone.
With a periosteal elevator, reect the periosteum, medially and
laterally, exposing the entire surface of the tibia between the
crest and the medial border. For better exposure at each end of
the longitudinal incision, incise the periosteum transversely; the
incision through the periosteum is shaped like an I.
Because of the shape of the tibia, the graft usually is wider at
the proximal end than at the distal end. This equalizes the
strength of the graft, because the cortex is thinner proximally
than distally. Before cutting the graft, drill a hole at each corner
of the anticipated area (Fig. 1-17).
With a single-blade saw, remove the graft by cutting through
the cortex at an oblique angle, preserving the anterior and
medial borders of the tibia. Do not cut beyond the holes,
especially when cutting across at the ends; overcutting here
weakens the donor bone and may serve as the starting point of
a future fracture. This is particularly true at the distal end of the
graft.
As the graft is pried from its bed, have an assistant grasp it
rmly to prevent its dropping to the oor.

Before closing the wound, remove additional cancellous bone


from the proximal end of the tibia with a curet. Take care to
avoid the articular surface of the tibia or, in a child, the physis.

19

The periosteum over the tibia is relatively thick in children and


usually can be sutured as a separate layer. In adults, it is often
thin, and closure may be unsatisfactory; suturing the periosteum
and the deep portion of the subcutaneous tissues as a single
layer usually is wise.

If the graft has been properly cut, little shaping is necessary.


Our practice is to remove the endosteal side of the graft for two
reasons: rst, the thin endosteal portion provides a graft to be
placed across from the cortical graft; second, the endosteal
surface, being rough and irregular, should be removed to ensure
good contact of the graft with the host bone.

Three points should be considered in the removal of a


bular graft: (1) the peroneal nerve must not be damaged;
(2) the distal fourth of the bone must be left to maintain
a stable ankle; and (3) the peroneal muscles should not
be cut.

Removal of Fibular Grafts


TECHNIQUE 1-2 Figs. 1-18 and 1-19
For most grafting procedures, resect the middle third or
middle half of the bula through a Henry approach (see
Chapter 37).

Dissect along the anterior surface of the septum between the


peroneus longus and soleus muscles.
Reect the peroneal muscles anteriorly after subperiosteal
dissection.

Tibial tuberosity

Begin the stripping distally and progress proximally so that the


oblique origin of the muscle bers from the bone tends to press
the periosteal elevator toward the bula.
Drill small holes through the bula at the proximal and distal
ends of the graft.
Connect the holes by multiple small bites with the bone-biting
forceps to osteotomize the bone; otherwise, the bone may be
crushed. A Gigli saw, an oscillating power saw, or a thin, airpowered cutting drill can be used. An osteotome may split or
fracture the graft. The nutrient artery enters the bone near the
middle of the posterior surface and occasionally may require
ligation.
If the transplant is to substitute for the distal end of the radius
or for the distal end of the bula, resect the proximal third of
the bula through the proximal end of the Henry approach, and
take care to avoid damaging the peroneal nerve.

Expose the nerve rst at the posteromedial aspect of the distal


Middle of shaft
Fig. 1-17 Method of removing tibial graft. Graft is wider
proximally than distally. A hole is drilled at each corner before
cutting to decrease stress riser effect of sharp corner after
removal of graft. Cortex is cut through at an oblique angle.

end of the biceps femoris tendon and trace it distally to where it


winds around the neck of the bula. In this location, the nerve is
covered by the origin of the peroneus longus muscle. With the
back of the knife blade toward the nerve, divide the thin slip of
peroneus longus muscle bridging it. Displace the nerve from its
normal bed into an anterior position.

20

Part I General Principles

Removal of Fibular Grafts


TECHNIQUE 1-2 Figs. 1-18 and 1-19contd
As the dissection continues, protect the anterior tibial vessels
that pass between the neck of the bula and the tibia by
subperiosteal dissection.
After the resection is complete, suture the biceps tendon and
the bular collateral ligament to the adjacent soft tissues.

Unless considerable strength is required,


the cancellous graft fullls almost any requirement.
Regardless of whether the cells in the graft remain viable,
clinical results indicate that cancellous grafts incorporate with the host bone more rapidly than do cortical
grafts.
Large cancellous and corticocancellous grafts may be
obtained from the anterior superior iliac crest and the
posterior iliac crest. Small cancellous grafts may be obtained from the greater trochanter of the femur, femoral
condyle, proximal tibial metaphysis, medial malleolus of the
tibia, olecranon, and distal radius. At least 2 cm of subchonCancellous Grafts

dral bone must remain to avoid collapse of the articular


surface.
If form and rigidity are unnecessary, multiple sliver or
chip grafts may be removed. When preservation of the iliac
crest is desirable, the outer cortex of the ilium may be
removed along with considerable cancellous bone. If a
more rigid piece of bone is desirable, the posterior or anterior one third of the crest of the ilium is a satisfactory
donor site. For wedge grafts, the cuts are made at a right
angle to the crest. Jones et al. found that full-thickness iliac
grafts harvested with a power saw are stronger than grafts
harvested with an osteotome, presumably because of less
microfracturing of bone with the saw.
If the patient is prone, the posterior third of the ilium
is used; if supine, the anterior third is available (Fig. 1-20).
In children, the physis of the iliac crest is ordinarily preserved together with the attached muscles. To accomplish
this, a cut is made parallel to and below the apophysis, and
this segment is fractured in greenstick fashion at the posterior end. Ordinarily, only one cortex and the cancellous
bone are removed for grafts, and the fractured crest, along
with the apophysis, is replaced in contact with the remnant
of the ilium and is held in place with heavy nonabsorbable

Line of incision
for tibial graft

Line of incision
for tibial graft

Tibial graft

Tibial graft

Deep and superficial


peroneal nerves

Fibula

Tibia

Tibia

Peroneus longus
and brevis
muscles
Fibula

Line of incision
for fibular graft
Soleus muscle
Section 97
Level near junction of upper and middle thirds of tibia

Section 93
Level of tibial tuberosity
Tibial graft
Fibula

Line of incision
for tibial graft
Tibia

Peroneus longus
and brevis
muscles
Flexor hallucis longus muscle
Line of incision
for fibular graft

Soleus muscle

Section 101
Level of junction of middle and lower thirds of tibia
Fig. 1-18 Cross sections of leg showing line of approach for removal of whole bular transplants
or tibial grafts. Colored segment shows portion of tibia to be removed. Thick, strong angles of
tibia are not violated.

Chapter 1 Surgical Techniques and Approaches

21

Common peroneal
nerve

Incision
Common peroneal
nerve

Gastrocnemius
muscle
Section
93

Biceps
muscle
Peroneal
muscles
(reflected)

Section
97

Soleus
muscle

Section
101

Fibula

Fig. 1-19 Resection of bula for transplant. A, Line of skin incision; levels of cross sections
shown in Figure 1-18 are indicated. B, Relation of common peroneal nerve to bular head
and neck. C, Henry method of displacing peroneal nerve to expose bular head and neck.

D
C
E

B
A

F
G

Fig. 1-20 Coronal sections (AD) from anterior portion of


ilium. Accompanying cross sections show width of bone and
its cancellous structure. Iliac grafts for fusion of spine are
ordinarily removed from posterior third of crest (EG).

sutures. When full-thickness grafts are removed from the


ilium in adults, a similar procedure may be used, preserving the crest of the ilium and its external contour. The
patient cannot readily detect the absence of the bone, and
the cosmetic result is superior. This method also is less
likely to result in a landslide hernia. Wolfe and Kawamoto
reported a method of taking full-thickness bone from
the anterior ilium; the iliac crest is split off obliquely
medially and laterally so that the edges of the crest may
be reapproximated after the bone has been excised (Fig.
1-21). They also used this method in older children without
any evidence of growth disturbance of the iliac crestal
physis.
Harvesting autograft bone from the ilium is not without
complications. Hernias have been reported to develop in
patients from whom massive full-thickness iliac grafts were
taken. The Davis muscle-pedicle graft for arthrodesis of the
hip (see Chapter 3) also has resulted in a hernia when both
cortices were removed. With this graft, the abductor
muscles and the layer of periosteum laterally are removed
with the graft. Careful repair of the supporting structures
remaining after removal of an iliac graft is important
and probably the best method of preventing these hernias.
Full-thickness windows made below the iliac crest are less
likely to lead to hernia formation. In addition to hernia
formation, nerve injury, arterial injury, or cosmetic deformity can be a problem after harvesting of iliac bone. The

22

Part I General Principles

Fig. 1-21 Wolfe-Kawamoto technique of taking iliac bone graft. A and B, Outer ridges of
iliac crest are split off obliquely with retention of muscular and periosteal attachments. C and
D, Closure of donor site. Note offset anteriorly for reattachment of crest to anterior superior
iliac spine (D). (Redrawn from Wolfe SA, Kawamoto HK: Taking the iliac-bone graft: a new technique, J Bone Joint Surg 60A:411, 1978.)

lateral femoral cutaneous and ilioinguinal nerves are at


risk during harvest of bone from the anterior ilium. The
superior cluneal nerves are at risk if dissection is carried
farther than 8 cm lateral to the posterior superior iliac
spine (Fig. 1-22). The superior gluteal vessels can be
damaged by retraction against the roof of the sciatic
notch. Removal of large full-thickness grafts from the

Line of dissection

Superior cluneal
nerves

anterior ilium can alter the contour of the anterior crest,


producing signicant cosmetic deformity (see Fig. 1-24).
Arteriovenous stula, pseudoaneurysm, ureteral injury,
anterior superior iliac spine avulsion, and pelvic instability
have been reported as major complications of iliac crest
graft procurement.

Removal of an Iliac Bone Graft


TECHNIQUE 1-3
Make an incision along the subcutaneous border of the iliac

8 cm

crest at the point of contact of the periosteum with the origins


of the gluteal and trunk muscles; carry the incision down to the
bone.

When the crest of the ilium is not required as part of the


Posterosuperior iliac
spine

graft, split off the lateral side or both sides of the crest in
continuity with the periosteum and the attached muscles. To
avoid hemorrhage, dissect subperiosteally.

If a cancellous graft with one cortex is desired, elevate only


the muscles from either the inner or the outer table of the ilium.
The inner cortical table with underlying cancellous bone may be
preferable owing to body habitus.

For full-thickness grafts, also strip the iliacus muscle from the
inner table of the ilium (Fig. 1-23).

Fig. 1-22 Posteroanterior view of pelvis showing superior


cluneal nerves crossing over posterior iliac crest beginning
8 cm lateral to posterior superior iliac spine. (Redrawn from
Garn SR, ed: Complications of spine surgery, Baltimore, 1989,
Williams & Wilkins.)

When chip or sliver grafts are required, remove them with an


osteotome or gouge from the outer surface of the wing of the
ilium taking only one cortex.
After removal of the crest, considerable cancellous bone may
be obtained by inserting a curet into the cancellous space
between the two intact cortices.

Chapter 1 Surgical Techniques and Approaches

23

When removing a cortical graft from the outer table, rst


outline the area with an osteotome or power saw. Then peel the
graft up by slight prying motions with a broad osteotome.
Wedge grafts or full-thickness grafts may be removed more
easily with a power saw; this technique also is less traumatic
than when an osteotome and mallet are used. For this purpose,
an oscillating saw or an air-powered cutting drill is satisfactory.
Avoid excessive heat by irrigating with saline at room
temperature. Avoid removing too much of the crest anteriorly
and leaving an unsightly deformity posteriorly (Fig. 1-24).
After removal of the grafts, accurately appose and suture the
periosteum and muscular origins with strong interrupted sutures.
Bleeding from the ilium is sometimes profuse; avoid using
Gelfoam and bone wax and depend on wound packing and local
pressure. Gelfoam and bone wax are foreign materials. Bone wax
is said to retard bone healing, and Gelfoam in large amounts has
been associated with sterile serous drainage from wounds.
Microcrystalline collagen has been reported to be more efcient
in reducing blood loss from cancellous bone than either
thrombin powder or thrombin-soaked gelatin foam. Gentle
wound suction for 24 to 48 hours combined with meticulous
obliteration of dead space has been satisfactory for the
management of these wounds at this clinic.

Fig. 1-23 Method of removing full-thickness coronal


segment of ilium. (Redrawn from Abbott LC: The use of iliac
bone in the treatment of ununited fractures. AAOS Instr Course
Lect 2:13, 1944.)

When harvesting bone from the posterior ilium, Colterjohn


and Bednar recommend making the incision parallel to the
superior cluneal nerves and perpendicular to the posterior iliac
crest (see Fig. 1-22).

SURGICAL APPROACHES
In the last several decades, many new surgical approaches
have been described, but few are truly original; many are
either old approaches rediscovered or modications of
approaches already in use. Not all approaches are described
in this chapter, but rather only those my coworkers and I
have found suitable for most of the orthopaedic operations
now in use. If, for some particular operation, an approach
is needed that is not described here, the reader may consult
the monographs and articles listed in the references at the
end of this chapter. Some additional approaches are
described in other sections of this book.
A surgical approach should provide easy access to all
structures sought. The incision should be long enough not
to hinder any part of the operation. When practical, it
should parallel or at least consider the natural creases of the
skin to avoid undesirable scars. A longitudinal incision on
the exor or extensor surface of a joint may cause a large,
unsightly scar or even a keloid that may permanently
restrict motion. A longitudinal midlateral incision, especially on a nger or thumb or on the ulnar border of the
hand, produces little scarring because it is located where

Fig. 1-24 Defect in ilium after large graft was removed.


Anterior border of ilium that included the anterior superior
iliac spine was preserved, but because the defect was so
large, deformity was visible even under clothing. Unsightly
contour was improved by removing more bone from the crest
posteriorly.

24

Part I General Principles

movements of the skin are relatively slight. The approach


also should do as little damage as possible to the deeper
structures. It should follow lines of cleavage and planes of
fascia and when possible should pass between muscles rather
than through them. Important nerves and vessels must be
spared by locating and protecting them or by avoiding
them completely; when an important structure is in immediate danger, it should be exposed. In addition to learning
approaches described by others, the surgeon should learn
anatomy so well that he or she can plan his or her own
approaches when necessary.
There has been more recent interest in less invasive total
joint arthroplasties. These approaches are outlined in
Chapters 6 to 8 and should be reserved for selected patients.
A smaller incision that makes the procedure much more
difcult to perform accurately can lead to disaster.
Unnecessary scarring and disgurement should be
avoided. Making a long incision parallel to the scar of a
previous long incision is unjustied. An incision through
an old scar heals as well as a new incision, and even though
the scar may not be ideally located, the deeper structures
may be reached by retracting the skin and subcutaneous
tissues. A second incision made parallel to and near an old
scar may impair the circulation in the strip of skin between
the two, leading to skin slough.
The position of the patient for surgery also is important.
It should be properly established before the operation is
begun, and provisions should be made to prevent undesirable changes in position during the operation. The surgeon
should be able to reach all parts of the surgical eld easily.
A pneumatic tourniquet, unless specically contraindicated, should always be used in surgery on the extremities;
the dry eld it provides makes the dissection easier, the
surgical technique less traumatic, and the time required for
the operation shorter. Also, in a dry eld, the cutaneous
nerves are identied and protected more easily, and they
often may be used as guides to deeper structures. The
identication, dissection, and ligation of vessels also are
made easier. Although the extremity is temporarily ischemic, an electrocautery unit should be used to cauterize
small vessels that cross the incision. An electrocautery unit
is even more useful in surgical sites where a tourniquet
cannot be employed, such as the shoulder, hip, spine, and
pelvis. The loss of blood and the time required for the
operation are reduced.

For the interphalangeal joints of the fth toe, make a lateral


incision.
Approach the interphalangeal joints of the second, third, and
fourth toes through an incision just lateral to the corresponding
extensor tendon.
Carry the dissection through the subcutaneous tissue and
fascia to the capsule of the joint.

Reect the edges of the incision with care to avoid damaging


the dorsal or plantar digital vessels and nerves; retract the dorsal
nerves and vessels dorsally and the plantar nerves and vessels
plantarward.

To expose the articular surfaces, open the capsule transversely


or longitudinally.

Approaches to the Metatarsophalangeal


Joint of the Great Toe
The metatarsophalangeal joint of the great toe may be
exposed in one of several ways. Two ways are discussed
here.
Head of first metatarsal
(area of bunion)
Dorsal digital nerve

Skin incision

A
Incision into bunion
and joint capsule

B
Flap of bunion
and joint capsule
Base of proximal phalanx

Toes
Approach to the Interphalangeal Joints
TECHNIQUE 1-4
For operations on the interphalangeal joint of the great toe,
make an incision 2.5 cm long on the medial aspect of the toe.

Head of first
metatarsal

C
Fig. 1-25 AC, Medial approach to metatarsophalangeal
joint of great toe (see text). (Modied from Hoppenfeld S,
deBoer P: Surgical exposures in orthopaedics: the anatomic approach,
Philadelphia, 2003, Lippincott Williams & Wilkins.)

Chapter 1 Surgical Techniques and Approaches

25

Medial Approach

Calcaneus

TECHNIQUE 1-5

Approaches to the calcaneus are carried out most easily


with the patient prone. The medial approach, however, can
be made with the patient supine, the knee exed, and the
foot crossed over the opposite leg. The lateral approach also
can be made with the patient supine by placing a sandbag
under the ipsilateral buttock, internally rotating the hip,
and inverting the foot.

Make a curved incision 5 cm long on the medial aspect of the


joint (Fig. 1-25A). Begin it just proximal to the interphalangeal
joint, curve it over the dorsum of the metatarsophalangeal joint
medial to the extensor hallucis longus tendon, and end it on the
medial aspect of the rst metatarsal 2.5 cm proximal to the joint.

As the deep fascia is incised, laterally retract the medial branch


of the rst dorsal metatarsal artery and the medial branch of the
dorsomedial nerve (a branch of the supercial peroneal nerve),
which supplies the medial side of the great toe.

Dissect the fascia from the dorsum down to the bursa over

Medial Approach
TECHNIQUE 1-8

the medial aspect of the metatarsal head.

Begin the incision 2.5 cm anterior to and 4 cm inferior to the

Make a curved incision through the bursa and capsule of the

medial malleolus, carrying it posteriorly along the medial surface


of the foot to the Achilles tendon.

joint (Fig. 1-25B); begin the incision over the dorsomedial aspect
of the joint, continue it proximally dorsal to the metatarsal head
and plantarward and distally around the joint, and end it distally
on the medioplantar aspect of the metatarsophalangeal joint.
This incision forms an elliptical, racquet-shaped ap, attached
at the base of the proximal phalanx (Fig. 1-25C). Although
distal reection of this ap amply exposes the rst
metatarsophalangeal joint, the use of a dorsomedial approach is
preferable because healing of the skin ap may be delayed.

Dorsomedial Approach
TECHNIQUE 1-6

Divide the fat and fascia and dene the inferior margin of the
abductor hallucis.
Mobilize the muscle belly and retract it dorsally to expose the
medial and inferomedial aspects of the body of the calcaneus.

Continue the dissection distally by dividing the plantar


aponeurosis and the muscles attaching to the calcaneus or by
stripping these from the bone with an osteotome. Carefully
avoid the medial calcaneal nerve and the nerve to the abductor
digiti minimi.
The inferior surface of the body of the calcaneus can be
exposed subperiosteally.

Begin the incision just proximal to the interphalangeal joint


and continue it proximally for 5 cm parallel with and medial to
the extensor hallucis longus tendon.

Lateral Approach

To expose the capsule, divide the fascia and retract the

TECHNIQUE 1-9

tendon.

Begin the incision on the lateral margin of the Achilles tendon

The capsule can be incised by forming a ap with its

near its insertion and pass it distally to a point 4 cm inferior to


and 2.5 cm anterior to the lateral malleolus (Fig. 1-27).

attachment at the base of the rst phalanx, as in the preceding


approach, or by continuing the dissection in the plane of the skin
incision.

Approach to the Metatarsophalangeal Joints


of the Lesser Toes

Divide the supercial and deep fasciae, isolate the peroneal


tendons, and incise and elevate the periosteum below the
tendons to expose the bone.
If necessary, and if no infection is present, divide the tendons
by Z-plasty and suture them later.

U Approach
TECHNIQUE 1-7
The second, third, and fourth metatarsophalangeal joints are
reached by a dorsolateral incision parallel to the corresponding
extensor tendon (Fig. 1-26).

TECHNIQUE 1-10
With the patient prone, support the leg on a large sandbag.

straight or curved dorsal or dorsolateral incision.

For access to the entire plantar surface of the calcaneus, join


the two approaches just described to form a large U-shaped
incision around the posterior four fths of the bone (Fig. 1-28).

The joint capsules may be opened transversely or


longitudinally, as necessary.

After the dissections described, retract a ap consisting of


skin, the fatty heel pad, and the plantar fascia.

The fth metatarsophalangeal joint is best exposed by a

26

Part I General Principles

Branches of superficial
peroneal nerve
Extensor digitorum longus
Deep peroneal nerve
Saphenous nerve
Tendon of extensor
digitorum longus

Deep
fascia

Fig. 1-26 Approaches to metatarsophalangeal joints of se cond, third, fourth, and fth
toes. A, Skin incision. B,
Incision through deep fascia
medial to tendons. C, Longitudinal incision in joint
capsule. D, Joint is exposed.
(Modied from Hoppenfeld S,
deBoer P: Surgical exposures in
orthopaedics: the anatomic approach,
Philadelphia, 2003, Lippincott
Williams & Wilkins.)

B
Base of proximal phalanx
Tendon of extensor
digitorum longus

Head of second
metatarsal

Joint
capsule

Peroneus
longus
muscle
Peroneus
brevis muscle

Skin incision

Incision in periosteum
of calcaneus

Calcaneus

Fig. 1-27 Lateral approach to calcaneus. A, Skin incision. B, Incision in periosteum of calcaneus. C, Calcaneus is exposed.

Chapter 1 Surgical Techniques and Approaches

27

Achilles tendon

Incision in
periosteum

Fig. 1-28 U approach to calcaneus.


A, Skin incision. B, Periosteal incision.
C, Incision in plantar aponeurosis and
muscles. D, Plantar aponeurosis and
muscles are retracted.

Calcaneus

Plantar
aponeurosis
and muscles
retracted

Incision in
plantar
aponeurosis
and muscles

Kocher Approach (Curved L)


The Kocher approach is suitable for complete excision of
the calcaneus in cases of tumor or infection.

TECHNIQUE 1-11
Incise the skin over the medial border of the Achilles tendon
from 7.5 cm proximal to the tuberosity of the calcaneus to the
inferoposterior aspect of the tuberosity, continuing it transversely
around the posterior aspect of the calcaneus and distally along
the lateral surface of the foot to the tuberosity of the fth
metatarsal (see Fig. 1-31B).
Divide the Achilles tendon at its insertion and carry the
dissection down to the bone.
To reach the superior surface, free all tissues beneath the
severed Achilles tendon.

The calcaneus may be enucleated with or without its


periosteal attachments.

Tarsus and Ankle


Anterolateral Approach
The anterolateral approach gives excellent access to the
ankle joint, the talus, and most other tarsal bones and
joints, and it avoids all important vessels and nerves. Because
so many reconstructive operations and other procedures
involve the structures exposed, it may well be called the
universal incision for the foot and ankle. It permits excision of the entire talus, and the only tarsal joints that it
cannot reach are those between the navicular and the
second and rst cuneiforms.
TECHNIQUE 1-12
Begin the incision over the anterolateral aspect of the leg
medial to the bula and 5 cm proximal to the ankle joint,
carrying it distally over the joint, the anterolateral aspect of the
body of the talus, and the calcaneocuboid joint, and end it at
the base of the fourth metatarsal (Fig. 1-29A). The incision may

28

Part I General Principles

Extensor digitorum
longus muscle
Transverse crural
ligament
Peroneal
tendons

Talus

Line of incision
Tibia
Cruciate crural
ligament
Navicular
Calcaneus

Cuboid

Extensor
digitorum brevis
muscle

B
Fig. 1-29

A and B, Anterolateral approach to ankle joint and tarsus.

TECHNIQUE 1-12contd
begin more proximally or end more distally, or any part may be
used, as needed.

Incise the fascia and the superior and inferior extensor


retinacula down to the periosteum of the tibia and the capsule
of the ankle joint. This dissection usually divides the anterolateral
malleolar and lateral tarsal arteries.
While retracting the edges of the wound, identify and protect
the intermediate dorsal cutaneous branches of the supercial
peroneal nerve.
Divide the extensor digitorum brevis muscle in the
direction of its bers or detach it from its origin and reect it
distally.
Retract the extensor tendons, the dorsalis pedis artery, and the
deep peroneal nerve medially and incise the capsule.

Expose the talonavicular joint by dissecting deep to the


tendon, and incise its capsule transversely.

Continue the dissection laterally through the capsule of the

Anterior Approach
Gaining access to the part of the ankle joint between the
medial malleolus and the medial articular facet of the body
of the talus often is difcult when fusing the ankle through
the anterolateral approach. Through the anterior approach,
however, both malleoli may be exposed easily. Usually the
approach is developed between the extensor hallucis longus
and extensor digitorum longus tendons (Fig. 1-30), but it
also can be developed between the anterior tibial and
extensor hallucis longus tendons. In this case, the neurovascular bundle is retracted laterally with the long extensor
tendons of the toes, and the anterior tibial tendon is
retracted medially.

TECHNIQUE 1-13
Begin the incision on the anterior aspect of the leg 7.5 to
10 cm proximal to the ankle and extend it distally to about
5 cm distal to the joint. Its length varies with the surgical
indication.

calcaneocuboid joint, which lies on the same plane as the


talonavicular joint.

Divide the deep fascia in line with the skin incision.

Incising a mass of fat lateral to and inferior to the neck of the


talus, bring the subtalar joint into view.

tarsal arteries, and carefully expose the neurovascular bundle and


retract it medially.

Extend the dissection distally to provide access to the

Incise the periosteum, capsule, and synovium in line with the

articulation between the cuboid and the fourth and fth


metatarsals and between the navicular and the third cuneiform
(Fig. 1-29B).

skin incision, and expose the full width of the ankle joint
anteriorly by subcapsular and subperiosteal dissection (see Fig.
1-30).

Isolate, ligate, and divide the anterolateral malleolar and lateral

Chapter 1 Surgical Techniques and Approaches

29

If a larger operative eld is necessary, divide the tendons by


Z-plasty and retract them.
Extensor hallucis
longus tendon
Anterior tibial
artery

Deepen the dissection distally, divide the calcaneobular


ligament, and expose the subtalar joint. The calcaneocuboid joint
may be reached through the distal part of this incision on the
same plane as the talonavicular.
After dividing the talobular ligaments, dislocate the ankle by
medial traction if access to its entire articular surface is desired.

Extensor digitorum
longus muscle

Deep peroneal
nerve

Talus
Navicular

Ollier Approach to the Tarsus


The Ollier approach is excellent for a triple arthrodesis: The
three joints are exposed through a small opening without
much retraction, and the wound usually heals well because
the proximal ap is dissected full thickness, and the skin
edges are protected during retraction (see Chapter 31).
TECHNIQUE 1-15
Begin the skin incision over the dorsolateral aspect of the
talonavicular joint, extend it obliquely inferoposteriorly, and end
it about 2.5 cm inferior to the lateral malleolus (see Fig. 1-31C).

Divide the inferior extensor retinaculum in the line of the skin


incision.
In the superior part of the incision, expose the long extensor
tendons to the toes and retract them medially, preferably
without opening their sheaths.
Fig. 1-30 Anterior approach to ankle joint. Extensor hallucis
longus and anterior tibial tendons, along with neurovascular
bundle, are retracted medially. Tendons of extensor digitorum longus muscle are retracted laterally.

In the inferior part of the incision, expose the peroneal


tendons and retract them inferiorly.
Divide the origin of the extensor digitorum brevis muscle,
retract the muscle distally, and bring into view the sinus tarsi.

Kocher Lateral Approach to the Tarsus and Ankle


The Kocher approach gives excellent exposure of the midtarsal, subtalar, and ankle joints (Fig. 1-31A). The disadvantage of this procedure is that the skin may slough
around the margins of the incision, especially if dislocation
of the ankle has been necessary, as in a talectomy. The
peroneal tendons usually must be divided. In most instances,
the anterolateral incision is more satisfactory.

Extend the dissection to expose the subtalar, calcaneocuboid,


and talonavicular joints.

TECHNIQUE 1-14

From a point just lateral and distal to the head of the talus,
curve the incision 2.5 cm inferior to the tip of the lateral
malleolus, then posteriorly and proximally, and end it 2.5 cm
posterior to the bula and 5 cm proximal to the tip of the lateral
malleolus or, if desired, 5 or 7 cm further proximally, parallel with
and posterior to the bula.
Incise the fascia down to the peroneal tendons and retract
them posteriorly, protecting the lesser saphenous vein and sural
nerve lying immediately posterior to the incision.

Fig. 1-31 A, Kocher approach to ankle. B, Kocher approach


to calcaneus. C, Ollier approach to midtarsal and subtalar
joints.

30

Part I General Principles

Posterolateral Approach to the Ankle


The Gatellier and Chastang posterolateral approach permits
open reduction and internal xation of fractures of the
ankle in which the fragment of the posterior tibial lip
(posterior malleolus) is large and laterally situated. It makes
use of the fact that the bula usually is fractured in such
injuries; should it be intact, it is osteotomized about 10 cm
proximal to the tip of the lateral malleolus. The approach
also is used for osteochondritis dissecans involving the
lateral part of the dome of the talus and for osteochondromatosis of the ankle.

TECHNIQUE 1-16

Gatellier and Chastang

Begin the incision about 12 cm proximal to the tip of the


lateral malleolus and extend it distally along the posterior margin
of the bula to the tip of the malleolus. Curve the incision
anteriorly for 2.5 to 4 cm in the line of the peroneal tendons (Fig.
1-32).

Expose the bula, including the lateral malleolus


subperiosteally, and incise the sheaths of the peroneal retinacula
and tendons, permitting the tendons to be displaced anteriorly.
If the bula is not fractured, divide it 10 cm proximal to the tip
of the lateral malleolus, and free the distal fragment by dividing
the interosseous membrane and the anterior and posterior
tibiobular ligaments.
Carefully preserve the calcaneobular and talobular ligaments
to serve as a hinge and to maintain the integrity of the ankle
after operation. Turn the bula laterally on this hinge, and

expose the lateral and posterior aspects of the distal tibia and
the lateral aspect of the ankle joint. Great care should be used in
children to avoid creating a fracture through the distal bular
physis when reecting the bula.

When closing the incision, replace the bula and secure it with
a screw extending transversely from the proximal part of the
lateral malleolus through the tibiobular syndesmosis into the
tibia just proximal and parallel to the ankle joint.
Overdrill the hole made in the bula to allow for compression
across the syndesmosis. Dorsiex the ankle joint as the screw is
tightened because the talar dome is wider at its anterior half
than its posterior half. Failure to overdrill the bula can result in
widening of the syndesmosis and ankle mortise, with resulting
arthritic degeneration of the tibiotalar joint. Add additional
xation with a small plate and screws if desired.
Replace the tendons, repair the tendon sheaths and retinacula,
and close the incision.
After the osteotomy or fracture has healed, remove the screw
to prevent its becoming loose or breaking.

Anterolateral Approach to the Lateral Dome of


the Talus
As an alternative to lateral malleolar osteotomy, Tochigi et
al. described an anterolateral approach to the lateral dome
of the talus for extensive lateral osteochondral lesions. All
but the posterior one fourth of the lateral talus can be
exposed. An osteotomy of the anterolateral tibia is
required.

Fig. 1-32 Posterolateral approach of Gatellier and Chastang. A, Peroneal tendons have been
displaced anteriorly, and bula has been divided; distal fragment has been turned laterally after
interosseous membrane and anterior and posterior tibiobular ligaments have been divided. B,
Distal bula has been replaced and xed to tibia with syndesmosis screw.

31

Chapter 1 Surgical Techniques and Approaches

Tibia

Fibula

Tibia
Osteotomy

Osteotomy

Fibula

Use a microoscillating saw to begin the osteotomy in two


planes. Complete the osteotomy with a small, narrow osteotome
by gently levering it in an externally rotated direction. The
cartilaginous surface of the tibia is cracked as the fragment is
rotated.
At wound closure, rotate the fragment back into position, and
secure it with a 4-mm cancellous screw and washer.

Talus

Talus

Lesion

Lesion

Posterior Approach to the Ankle

Anterolateral approach to talus. A, Anterior view


of osteotomy. B, Lateral view of osteotomy. (From Tochigi
Y, Amendola A, Muir D, et al: Surgical approach for centrolateral
talar osteochondral lesions with an anterolateral osteotomy, Foot
Ankle Int 23:1038, 2002.)
Fig. 1-33

TECHNIQUE 1-17

Tochigi, Amendola, Muir, and

Saltzman

Make a vertical 10-cm incision along the anterolateral corner


of the ankle, avoiding the lateral branch of the supercial
peroneal nerve.
Outline the osteotomy of the anterolateral tibia to include
the anterior tibiobular ligament. The cortical surface of the
fragment should be at least 1 cm2 (Fig. 1-33). Predrill the
fragment to accept a 4-mm cancellous screw.

TECHNIQUE 1-18
With the patient prone, make a 12-cm incision along the
posterolateral border of the Achilles tendon down to the
insertion of the tendon on the calcaneus (Fig. 1-34).
Divide the supercial and deep fasciae, lengthen the Achilles
tendon by Z-plasty or retract it, and incise the fat and areolar
tissue to the posterior surface of the tibia in the space between
the exor hallucis longus and the peroneal tendons.
Retract the exor hallucis longus tendon medially to expose
2.5 cm of the distal end of the tibia, the posterior aspect of the
ankle joint, the posterior end of the talus, the subtalar joint, and
the posterior part of the superior surface of the calcaneus.

If the dissection is kept lateral to the exor hallucis longus


tendon, the posterior tibial vessels and the tibial nerve will not
be damaged because this tendon protects them.

Gastrocnemius
muscle

Tibia
Tibial nerve
Line of
skin incision

Flexor hallucis
longus muscle

Flexor hallucis
longus muscle

Posterior tibial
artery
Talus
Subtalar joint

Gastrocnemius
tendon

Fig. 1-34 Posterior approach to ankle. A, Skin incision. B, Z-plasty division and reection of
Achilles tendon. C, Exposure of ankle and subtalar joints after retraction of exor hallucis
longus tendon and posterior capsulotomy.

Ankle joint

32

Part I General Principles

teum and retracting the tendons of the posterior tibial,


exor digitorum longus, and exor hallucis longus muscles
together with the neurovascular bundle posteriorly and
medially.
Colonna and Ralston described the following modication of Broomheads approach.
TECHNIQUE 1-20

Fig. 1-35 Incisions for medial approaches to ankle joint.


Koenig and Schaefer (A). Broomhead (B). Colonna and
Ralston (C).

Medial Approaches to the Ankle


Koenig and Schaefer approached the ankle from the medial
side by a method similar in principle to the Gatellier and
Chastang exposure of the posterolateral side. It is not a
popular method because despite utmost care, it is possible
to injure the tibial vessels and nerve. Nevertheless, it may
be useful for fracture-dislocations of the talus, other traumatic lesions of the ankle joint, and osteochondritis dissecans of the talus.
TECHNIQUE 1-19

Colonna and Ralston

Begin the incision at a point about 10 cm proximal and 2.5 cm


posterior to the medial malleolus and curve it anteriorly and
inferiorly across the center of the medial malleolus and inferiorly
and posteriorly 4 cm toward the heel (see Fig. 1-35C).
Expose the medial malleolus by reecting the periosteum, but
preserve the deltoid ligament.
Divide the exor retinaculum and retract the exor hallucis
longus tendon and the neurovascular bundle posteriorly and
laterally.
Retract the tibial posterior and exor digitorum longus tendons
medially and anteriorly to expose the posterior tibial fracture (Fig.
1-37).

In addition to the approaches described, short medial, lateral,


and dorsal approaches may be made to expose small areas of
the tarsal and metatarsal joints. In all, the vessels, nerves, and
tendons must be protected.

Koenig and Schaefer

Curve the incision just proximal to the medial malleolus


(Fig. 1-35A), and divide the malleolus with an osteotome or small
power saw; preserve the attachment of the deltoid ligament.

Subluxate the talus and malleolus laterally to reach the joint


surfaces.

Tibia
Anterior Approach
The tibia is a supercial bone that can be easily exposed
anteriorly without damaging any important structure

Later replace the malleolus and x it with a cancellous screw.


To make replacement easier, drill the hole for the screw before
osteotomy, insert the screw, and then remove it. At the end of
the operation, reinsert the screw and close the wound.
The surfaces of the osteotomized bone are smooth, and the
malleolus may rotate on a single screw; the addition of one or
two small threaded wires may be necessary to stabilize the
xation. Alternatively, two screws can be used to prevent
rotation of the osteotomized medial malleolus (Fig. 1-36).
Interfragmentary technique (see Chapter 50) should be used for
screw xation of the medial malleolus to provide compression
across the osteotomy site.

Broomhead advised a curved medial incision for fractures of the medial part of the posterior lip of the tibia that
require open reduction. The line of approach lies midway
between the posterior border of the tibia and the medial
border of the Achilles tendon, curves inferior to the medial
malleolus to the medial border of the foot, and permits
exposure of medial and posterior malleoli (see Fig. 1-35B).
The latter is exposed by reecting the capsule and perios-

Fig. 1-36 Osteotomy of medial malleolus for access to


medial dome of the talus. Note line of osteotomy.

Chapter 1 Surgical Techniques and Approaches

Flexor digitorum
longus tendon

33

TECHNIQUE 1-23 Harmon, Modied


Flexor hallucis
longus tendon

Tibialis posterior
tendon
Posterior
tibial artery
Tibial nerve

Position the patient prone or on the side, with the affected


extremity uppermost.

Extend the skin incision the desired length along the lateral
border of the gastrocnemius muscle on the posterolateral aspect
of the leg (Fig. 1-38A).
Develop the plane between the gastrocnemius, the soleus, and
the exor hallucis longus muscles posteriorly and the peroneal
muscles anteriorly (Fig. 1-38B).
Find the lateral border of the soleus muscle and retract it and
the gastrocnemius muscle medially and posteriorly; arising from
the posterior surface of the bula is the exor hallucis longus
(Fig. 1-38C).

Fig. 1-37 Colonna and Ralston posteromedial approach to


distal tibia. Posterior tibial and exor digitorum longus
tendons have been retracted anteriorly, and exor hallucis
longus tendon, posterior tibial vessels, and tibial nerve have
been retracted posteriorly and laterally.

except the tendons of the anterior tibial and extensor hallucis longus muscles, which cross the tibia anteriorly in its
lower fourth.
TECHNIQUE 1-21
Make a longitudinal incision on either side of the anterior
border of the bone.

Reect the skin, and incise and elevate the periosteum over
the desired area.
Strip the periosteum as little as possible, because its circulation
is a source of nutrition for the bone.

Medial Approach
In some delayed unions and nonunions, Phemister inserted
a bone graft in a bed prepared on the posterior surface of
the tibia.
TECHNIQUE 1-22 Phemister
Make a longitudinal incision along the posteromedial border of
the tibia.

Incise the subcutaneous tissues and deep fascia, and reect


the periosteum from the posterior surface for the required
distance.

Posterolateral Approach
The posterolateral approach is valuable in the middle two
thirds of the tibia when the anterior and anteromedial
aspects of the leg are badly scarred. It also is satisfactory
for removing a portion of the bula for transfer.

Detach the distal part of the origin of the soleus muscle


from the bula, and retract it posteriorly and medially (Fig.
1-38D).
Continue the dissection medially across the interosseous
membrane, detaching those bers of the posterior tibial muscle
arising from it (Fig. 1-38E). The posterior tibial artery and the
tibial nerve are posterior and separated from the dissection by
the posterior tibial and exor hallucis longus muscles (Fig. 1-38F).

Follow the interosseous membrane to the lateral border of the


tibia and detach subperiosteally the muscles that arise from the
posterior surface of the tibia (Fig. 1-38G and H).
The posterior half of the bula lies in the lateral part of the
wound; its entire shaft can be explored. The at posterior
surface of the tibial shaft can be completely exposed except for
its proximal fourth, which lies in close relation to the popliteus
muscle and to the proximal parts of the posterior tibial vessels
and the tibial nerve.

When the operation is completed, release the tourniquet,


secure hemostasis, and let the posterior muscle mass fall back
into place.
Loosely close the deep fascia on the lateral side of the leg
with a few interrupted sutures.

Posterior Approach to the Superomedial Region


of the Tibia
TECHNIQUE 1-24 Banks and Laufman
The patient must be prone. Begin the transverse segment of
the hockey-stick incision (Fig. 1-39A) at the lateral end of the
exion crease of the knee, and extend it across the popliteal
space. Turn the incision distally along the medial side of the calf
for 7 to 10 cm.
Develop the angular ap of skin and subcutaneous tissue, and
incise the deep fascia in line with the skin incision (Fig. 1-39B).
Identify and protect the cutaneous nerves and supercial vessels.

34

Part I General Principles

Fascia over peroneus longus

Fascia over lateral head


of gastrocnemius

Gastrocnemius-soleus mass

Fascia over soleus

B
Peronei
Fibula

Flexor hallucis longus

Extensor digitorum
Interosseous membrane

Gastrocnemius

Anterior tibial muscle


Soleus
Anterior tibial artery
Peroneal artery
Deep peroneal nerve
Tibial nerve

Tibia

Posterior tibial artery

Flexor digitorum longus

Posterior tibial muscle


Peroneus brevis (retracted)

Fibula

Soleus (origin)
Lateral edge of fibula

Peroneus longus

Peroneus longus

Flexor hallucis
longus

Flexor hallucis longus


Soleus

Fascia over lateral head


of gastrocnemius

Soleus (retracted)

Fascia over lateral head


of gastrocnemius

Soleus (detached)

Soleus
(detached)

Fig. 1-38 Posterolateral approach to tibia. A, Skin incision. B, Plane between gastrocnemius,
soleus, and exor hallucis longus posteriorly and peroneal muscles anteriorly is developed. C,
Flexor hallucis longus arising from posterior surface of bula. D, Distal part of origin of soleus
is detached from bula and retracted posteriorly and medially. E, Dissection medially across
interosseous membrane, detaching bers of posterior tibial muscle.

Chapter 1 Surgical Techniques and Approaches

35

Peronei

Flexor hallucis longus

Fibula
Interosseous membrane
Extensor digitorum longus
Anterior tibial muscle

Soleus

Anterior tibial artery

Peroneal artery

Deep peroneal nerve

Gastrocnemius

Tibia

Tibia nerve
Flexor digitorum longus

Posterior tibial artery

Posterior tibial muscle

F
Peroneus longus
(retracted)
Fibula

Soleus
(retracted)

Interosseous
membrane

Peroneus longus
(retracted)

Lateral edge
of tibia

Tibia

Fibula

Flexor hallucis longus


(retracted)

Flexor hallucis longus


(retracted)

Interosseous
membrane

Periosteum

Fascia over soleus

Fig. 1-38, contd F, Posterior tibial artery and tibial nerve are protected by posterior tibial and
exor hallucis longus muscles. G and H, Muscles are detached subperiosteally from posterior
surface of tibia. (Modied from Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the anatomic
approach, Philadelphia, 2003, Lippincott Williams & Wilkins.)

TECHNIQUE 1-24 Banks and Laufmancontd

Fibula

Dene the interval between the tendon of the semitendinosus

Posterolateral Approach

muscle and the medial head of the gastrocnemius muscle.

Retract the semitendinosus proximally and medially and the


gastrocsoleus component distally and laterally; the popliteus and
exor digitorum longus muscles lie in the oor of the interval
(Fig. 1-39C).

Elevate subperiosteally the exor digitorum longus muscle


distally and laterally and the popliteus muscle proximally and
medially, and expose the posterior surface of the proximal fourth
of the tibia (Fig. 1-39D).

If necessary, extend the incision distally along the medial side


of the calf by continuing the dissection in the same intermuscular
plane. The tibial nerve and posterior tibial artery lie beneath the
soleus muscle.

TECHNIQUE 1-25 Henry


Beginning 13 cm proximal to the lateral malleolus, incise the
skin proximally along the posterior margin of the bula to the
posterior margin of the head of the bone, and continue farther
proximally for 10 cm along the posterior aspect of the biceps
tendon.
Divide the supercial and deep fasciae. Isolate the common
peroneal nerve along the posteromedial aspect of the biceps
tendon in the proximal part of the wound, and free it distally to
its entrance into the peroneus longus muscle (Fig. 1-40).
Pointing the knife blade proximally and anteriorly, detach the
part of the peroneus longus muscle that arises from the lateral

36

Part I General Principles

Medial

Small
saphenous
vein

Lateral

Medial sural
cutaneous
nerve
Fascia
Semitendinosus
muscle
Medial
head of
gastrocnemius
muscle

B
Semitendinosus
muscle

Popliteus
muscle

Popliteus
muscle

Flexor digitorum
longus muscle
Tibia

Gastrocnemius and
soleus muscles

Gastrocnemius and
soleus muscles

Flexor digitorum
longus muscle

Fig. 1-39 Banks and Laufman posterior approach to superomedial region of tibia. A, Incision
extends transversely across popliteal fossa, then turns distally on medial side of calf. B, Skin
and deep fascia have been incised and reected. C, Broken line indicates incision to be made
between popliteus and exor digitorum longus. D, Popliteus and exor digitorum longus have
been elevated subperiosteally to expose tibia.

TECHNIQUE 1-25 Henrycontd


surface of the head of the bula proximal to the common
peroneal nerve. Retract the nerve over the head of the bula.

The distal fourth of the bula is subcutaneous on its lateral


aspect and may be exposed by a longitudinal incision through
the skin, fascia, and periosteum.

Locate the fascial plane between the soleus muscle posteriorly


and the peroneal muscles anteriorly, and deepen the dissection
along the plane to the bula.

Expose the bone by retracting the peroneal muscles anteriorly


and incising the periosteum. When retracting these muscles,
avoid injuring the branches of the deep peroneal nerve that lie
on their deep surfaces and are in close contact with the neck of
the bula and proximal 5 cm of the shaft.

Knee
Anteromedial and Anterolateral Approaches
When any anteromedial approach is made, including one
for meniscectomy, the infrapatellar branch of the saphenous
nerve should be protected (Fig. 1-41). The saphenous nerve
courses posterior to the sartorius muscle, then pierces the
fascia lata between the tendons of the sartorius and gracilis

Chapter 1 Surgical Techniques and Approaches

Biceps femoris
muscle

Common
peroneal
nerve

Common
peroneal
nerve

Posterior cutaneous
nerve of the calf

37

Head of fibula
Tibial nerve
Peroneus
longus muscle
Gastrocnemius
muscle

Peroneus
longus muscle
Soleus muscle

Method of mobilizing and retracting common peroneal nerve when approaching


proximal bula. A, Anatomical relationships. B, Part of peroneus longus that arises from lateral
surface of bular head proximal to common peroneal nerve has been detached, allowing nerve
to be retracted over bular head.
Fig. 1-40

muscles and becomes subcutaneous on the medial aspect of


the leg; on the medial aspect of the knee, it gives off a large
infrapatellar branch to supply the skin over the anteromedial aspect of the knee. Kummel and Zazanis and Chambers
noted several variations in the location and distribution of
this infrapatellar branch. Consequently, no single incision

Rectus femoris
muscle
Vastus medialis
muscle
Sartorius muscle
Patella

Patellar
tendon

Saphenous vein
Infrapatellar branch
of saphenous nerve

on the anteromedial aspect of the knee can avoid it for


certain. Kummel and Zazanis use blunt dissection between
the skin and joint capsule to locate the nerve and its
branches; the branches are carefully freed and retracted out
of harms way during surgery. Chambers also advises looking
for the nerve and carefully protecting it. Chambers described
several patients in whom operations on the knee were
unsuccessful because of neuromas in the scar.
Usually the anterolateral approach is not as satisfactory
as the anteromedial one, primarily because it is more difcult to displace the patella medially than laterally. It also
requires a longer incision, and often the patellar tendon
must be partially freed subperiosteally or subcortically.
Keblish has used the anterolateral approach successfully in
total knee arthroplasty for xed valgus deformity. The
iliotibial band can be released or lengthened, and the tight
posterolateral corner can be released easily. The bular
head can be resected through the same incision to decompress the peroneal nerve if necessary.

Saphenous nerve

Gastrocnemius muscle

Fig. 1-41 Anatomical relationships of supercial structures


on medial aspect of knee.

Anteromedial Parapatellar Approach


TECHNIQUE 1-26 Langenbeck
Begin the incision at the medial border of the quadriceps
tendon 7 to 10 cm proximal to the patella, curve it around the
medial border of the patella and back toward the midline, and
end it at or distal to the tibial tuberosity (Fig. 1-42). As a more

38

Part I General Principles

Vastus lateralis
muscle

Rectus femoris
muscle

Sartorius muscle
Iliotibial band
Vastus medialis
muscle
Suprapatellar
bursa
Lateral femoral
condyle

Medial femoral
condyle

Patella
Lateral
meniscus

Tibial
tuberosity

Posterior cruciate
ligament

Fibular head
Peroneus longus
muscle

Anterior cruciate
ligament

Fig. 1-42

Extensor
digitorum
longus
muscle

Tibial
tuberosity
Gastrocnemius
muscle
Anterior tibial
muscle

Anteromedial approach to knee joint.

Anteromedial Parapatellar Approach


TECHNIQUE 1-26 von Langenbeckcontd
cosmetically pleasing alternative, a longitudinal incision centered
over the patella can be made, reecting the subcutaneous tissue
and supercial fascia over the patella medially by blunt dissection
to the medial border of the patella.

If contracture of the quadriceps prevents sufcient exposure,


detach the tibial tuberosity and reattach later with a screw.
Fernandez described an extensive osteotomy of the tibial
tuberosity (see Fig. 1-54) and reattachment of the tuberosity
with three lag screws engaging the posterior tibial cortex. This
technique achieves rigid xation and allows early postoperative
rehabilitation.

Divide and retract the fascia.


Deepen the dissection between the vastus medialis muscle and
the medial border of the quadriceps tendon, and incise the
capsule and synovium along this medial border and along the
medial border of the patella and patellar tendon.
Retract the patella laterally and ex the knee to gain a good
view of the anterior compartment of the joint and the
suprapatellar bursa.
Attain wider access to the joint in the following ways:
(1) extending the incision proximally, (2) extending the proximal
part of the incision obliquely medially and separating the bers
of the vastus medialis, (3) dividing the medial alar fold and
adjacent fat pad longitudinally, and (4) mobilizing the medial part
of the insertion of the patellar tendon subperiosteally.

Problems with patellar dislocation, subluxation, and osteonecrosis after total knee arthroplasty performed through an
anteromedial parapatellar approach led to the rediscovery
of the subvastus, or Southern, anteromedial approach rst
described by Erkes in 1929. According to Hofmann et al.,
this approach preserves the vascularity of the patella by
sparing the intramuscular articular branch of the descending genicular artery and preserves the quadriceps tendon,
providing more stability to the patellofemoral joint in total
knee arthroplasty. This approach also is useful for lesser
anteromedial and medial knee procedures. The relative
contraindications to this approach are previous major knee
arthroplasty and weight greater than 200 lb, which makes
eversion of the patella difcult.

Chapter 1 Surgical Techniques and Approaches

Medial patellar retinaculum

Patella

39

Vastus medialis muscle

Fascial layer 1

Fascial layer 1

A
Vastus medialis
muscle

Everted patella

Anterior cruciate
ligament

Patella

Lateral fat pad

Patellar
tendon

Medial patellar
retinaculum

Vastus
medialis
muscle

Arthrotomy
Medial meniscus
Medial collateral
ligament

D
Fig. 1-43 Subvastus anteromedial approach. A, Supercial fascia is incised medial to patella.
B, Supercial fascia is bluntly elevated from perimuscular fascia of vastus medialis down to its
insertion on medial patellar retinaculum. C, Tendinous insertion elevated by blunt dissection.
Line indicates arthrotomy. D, Patella is everted, and knee is exed. (Redrawn from Hofmann
AA, Plaster RL, Murdock LE: Subvastus (Southern) approach for primary total knee arthroplasty, Clin
Orthop 269:70, 1991.)

Subvastus (Southern) Anteromedial


Approach
TECHNIQUE 1-27

Erkes, as described by Hofmann,

Plaster, and Murdock

Exsanguinate the limb and inate the tourniquet with the knee
exed to 90 degrees to prevent tenodesis of the extensor
mechanism.

muscle anteriorly and perform an L-shaped arthrotomy beginning


medially through the vastus insertion on the medial patellar
retinaculum and carrying it along the medial edge of the patella.

Partially release the medial edge of the patella tendon and


evert the patella laterally with the knee extended (Fig. 1-43D).

Anterolateral Approach

Make a straight anterior skin incision, beginning 8 cm above


the patella, carrying it distally just medial and 2 cm distal to the
tibial tubercle.

TECHNIQUE 1-28

Incise the supercial fascia slightly medial to the patella (Fig. 1-

Begin the incision 7.5 cm proximal to the patella at the


insertion of the vastus lateralis muscle into the quadriceps
tendon; continue it distally along the lateral border of this
tendon, the patella, and the patellar tendon; and end it 2.5 cm
distal to the tibial tuberosity.

43A), and bluntly dissect it off the vastus medialis muscle fascia
down to the muscle insertion (Fig. 1-43B).

Identify the inferior edge of the vastus medialis, and bluntly


dissect it off the periosteum and intermuscular septum for a
distance of 10 cm proximal to the adductor tubercle.

Identify the tendinous insertion of the muscle on the medial


patellar retinaculum (Fig. 1-43C), and lift the vastus medialis

Kocher

Deepen the dissection through the joint capsule.


Retract the patella medially, with the tendons attached to it,
and expose the articular surface of the joint (Fig. 1-44).

40

Part I General Principles

Rectus femoris
muscle
Vastus lateralis
muscle
Sartorius muscle
Iliotibial band
Vastus medialis
muscle

Medial patellar
retinaculum

A
Biceps tendon
Patella
Peroneus longus
muscle

Anterior cruciate
ligament

Latral femoral
condyle

Posterior cruciate
ligament

Lateral
meniscus

Extensor
digitorum
longus muscle

Transverse
ligament
Anterior tibial
muscle

Fibular
collateral
ligament

Tibial
tuberosity

Fibular head

Patellar tendon
Infrapatellar
branch of
saphenous nerve
Gastrocnemius
muscle
Medial surface
of tibia

Lateral surface
of tibia

C
Fig. 1-44

A-C, Kocher anterolateral approach to knee joint.

Posterolateral and Posteromedial Approaches


In some patients, a median septum separates the posterior
aspect of the knee into two compartments. The posterior
cruciate ligament is extrasynovial and projects anteriorly in
the septum; it contributes to the partition between the two
posterior compartments. The middle genicular artery
courses anteriorly in the septum to nourish the tissues of
the intercondylar notch of the femur (Fig. 1-45). The presence of this septum may assume great importance when
exploring the posterior aspect of the knee for a loose body
or when draining the joint in the rare instances in which
pyogenic arthritis of the knee requires posterior drainage.
In the latter, both posterior compartments must be opened
for drainage, not one alone (see Chapter 17).

Fenestra in
intercondylar
septum
Middle genicular
artery

Posterior cruciate
ligament
Ligamentum
mucosum
Anterior cruciate
ligament

Posterolateral Approach
TECHNIQUE 1-29 Henderson
With the knee exed 90 degrees, make a curved incision on
the lateral side of the knee, just anterior to the biceps femoris
tendon and the head of the bula (Fig. 1-46), and avoid the

Fig. 1-45 Median septum separating two posterior compartments of knee. Note fenestra at proximal pole. Synovial
septum invests cruciate ligaments and contains branch of
middle genicular artery.

Chapter 1 Surgical Techniques and Approaches

common peroneal nerve, which passes over the lateral aspect of


the neck of the bula.

Posteromedial Approach

In the proximal part of the incision, trace the anterior surface


of the lateral intermuscular septum to the linea aspera 5 cm
proximal to the lateral femoral condyle.

With the knee exed 90 degrees, make a curved incision,


slightly convex anteriorly and approximately 7.5 cm long, distally
from the adductor tubercle and along the course of the tibial
collateral ligament, anterior to the relaxed tendons of the
semimembranosus, semitendinosus, sartorius, and gracilis
muscles (Fig. 1-47).

Expose the lateral femoral condyle and the origin of the bular
collateral ligament.

The tendon of the popliteus muscle lies between the biceps


tendon and the bular collateral ligament; mobilize and retract it
posteriorly, and expose the posterolateral aspect of the joint
capsule.

Make a longitudinal incision through the capsule and synovium


of the posterior compartment.

TECHNIQUE 1-30 Henderson

Expose and incise the oblique part of the tibial collateral


ligament, and incise the capsule longitudinally and enter the
posteromedial compartment of the knee posterior to the
tibial collateral ligament, retracting the hamstring tendons
posteriorly.

Rectus femoris muscle


Vastus lateralis muscle
Iliotibial band

Biceps
femoris
muscle
Common
peroneal
nerve

Lateral head of
gastrocnemius
muscle

Fibular head

Common peroneal
nerve
Peroneus longus
muscle

Extensor digitorum
longus muscle

Anterior tibial
muscle

Soleus muscle

Posterolateral
joint capsule

Biceps femoris
muscle

Lateral head of
gastrocnemius
muscle
Lateral femoral
condyle

Fig. 1-46

Henderson posterolateral approach to knee joint.

Fibular
collateral
ligament

41

42

Part I General Principles

Rectus femoris muscle


Vastus medialis muscle
Quadriceps tendon

Patella

Infrapatellar
branch of
saphenous
nerve

Gracilis muscle
Semimembranosus
muscle
Semitendinosus
muscle
Sartorius muscle
Gastrocnemius
muscle

Medial femoral
condyle

Medial
meniscus

C
Fig. 1-47

A-C, Henderson posteromedial approach to knee joint.

Medial Approaches to the Knee and Supporting


Structures
Usually the entire medial meniscus can be excised through
a medial parapatellar incision about 5 cm long. If the posterior horn of the meniscus cannot be excised through this
incision, a separate posteromedial Henderson approach can
be made (see Fig. 1-47). The anterior and posterior compartments may be entered, however, through an approach
in which only one incision is made through the skin but
two incisions are used through the deeper structures; this
type of approach is rarely indicated. The Cave approach is

a curved incision that allows exposure of the anterior and


posterior compartments.
TECHNIQUE 1-31 Cave
With the knee exed at a right angle, identify the medial
femoral epicondyle, and begin the incision 1 cm posterior to and
on a level with it approximately 1 cm proximal to the joint line.
Carry the incision distally and anteriorly to a point 0.5 cm distal
to the joint line and anterior to the border of the patellar
tendon.

43

Chapter 1 Surgical Techniques and Approaches

Medial femoral condyle


Femoral condyle

Incisions into
capsule

Capsule

Medial
meniscus

Exposure of anterior and posterior compartments of knee joint through one skin
incision, according to Cave. A, Single skin incision. B, Two incisions through deep structures.
C, Removal of meniscus.
Fig. 1-48

After reecting the subcutaneous tissues, expose the anterior


compartment through an incision that begins anterior to the
tibial collateral ligament, continues distally and anteriorly in a
curve similar to that of the skin incision, and ends just distal to
the joint line (Fig. 1-48).
To expose the posterior compartment, make a second
deep incision posterior to the tibial collateral ligament, from
the level of the femoral epicondyle straight distally across the
joint line.

TECHNIQUE 1-32 Hoppenfeld and deBoer


With the patient supine and the affected knee exed about 60
degrees, place the foot on the opposite shin, and abduct and
externally rotate the hip.
Begin the incision 2 cm proximal to the adductor tubercle of
the femur, curve it anteroinferiorly about 3 cm medial to the
medial border of the patella, and end it 6 cm distal to the joint
line on the anteromedial aspect of the tibia (Fig. 1-49A).
Retract the skin aps to expose the fascia of the knee, and
extend the exposure from the midline anteriorly to the
posteromedial corner of the knee (Fig. 1-49B).
Cut the infrapatellar branch of the saphenous nerve and bury
its end in fat; preserve the saphenous nerve itself and the long
saphenous vein.

Longitudinally incise the fascia along the anterior border of the


sartorius, starting at the tibial attachment of the muscle and
extending it to 5 cm proximal to the joint line.
Flex the knee further, and allow the sartorius to retract
posteriorly, exposing the semitendinosus and gracilis muscles (Fig.
1-49C).

Retract all three components of the pes anserinus posteriorly,


and expose the tibial attachment of the tibial collateral ligament,
which inserts 6 to 7 cm distal to the joint line (Fig. 1-49D).
To open the joint anteriorly, make a longitudinal medial
parapatellar incision through the retinaculum and synovium (Fig.
1-49E).
To expose the posterior third of the medial meniscus and the
posteromedial corner of the knee, retract the three components
of the pes anserinus posteriorly (Fig. 1-49F), and separate the
medial head of the gastrocnemius muscle from the posterior
capsule of the knee almost to the midline by blunt dissection
(Fig. 1-49G).
To open the joint posteriorly, make an incision through the
capsule posterior to the tibial collateral ligament.

Transverse Approaches to the Menisci


The advantage of the transverse approach to the medial
meniscus is that the scar has no contact with the femoral
articular surface.
TECHNIQUE 1-33
Make a transverse incision 5 cm long at the level of the
articular surface of the tibia, extending laterally from the medial
border of the patellar tendon to the anterior border of the tibial
collateral ligament (Fig. 1-50).
Incise the capsule along the same line, and dissect the
proximal edge of the divided capsule from the underlying
synovium and retract it proximally.
Open the synovium along the proximal border of the medial
meniscus. Charnley advised making a preliminary 1.5-cm opening

44

Part I General Principles

Adductor
tubercle

Tibial
tuberosity

Medial patellar
retinaculum

Vastus medialis

Medial patellar
retinaculum (retracted)
Fascia over
vastus medialis

Sartorius

Medial head of gastrocnemius


Infrapatellar
branch of
saphenous
nerve

Posteromedial joint capsule


Semitendinosus
Anterior joint
capsule

Sartorius
Semimembranosus

Medial
meniscus
Gracilis
Superficial tibial
collateral ligament

Medial patellar retinaculum


(retracted)
Fascia over vastus medialis

Medial femoral condyle

Medial head of gastrocnemius


Posteromedial joint capsule
Superficial tibial
collateral ligament
and its tibial
insertion

Tendon of semimembranosus
Fascia over sartorius

Medial patellar
retinaculum

Medial head of
gastrocnemius

E
Fig. 1-49 Medial approach to knee and supporting structures. A, Skin incision. B, Skin aps
have been retracted. C, Sartorius has been retracted posteriorly, exposing semitendinosus and
gracilis. D, All three components of pes anserinus have been retracted posteriorly to expose
tibial attachment of tibial collateral ligament. E, Medial parapatellar incision has been made
through retinaculum and synovium.

Chapter 1 Surgical Techniques and Approaches

Medial patellar retinaculum


(retracted)

Medial patellar retinaculum


(retracted)

Medial head of
gastrocnemius
Posteromedial
joint capsule

Medial head of
gastrocnemius

Superficial tibial
collateral ligament
Medial femoral
condyle

Superficial tibial
collateral ligament
Semimembranosus
Sartorius

45

Semimembranosus
Sartorius

Posteromedial view

Posteromedial view

Fig. 1-49, contd F, Three components of pes anserinus have been retracted posteriorly to expose
posteromedial corner. G, Medial head of gastrocnemius has been separated from posterior
capsule of knee and has been retracted. Capsulotomy is made posterior to tibial collateral ligament. (Modied from Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the anatomic approach,
Philadelphia, 2003, Lippincott Williams & Wilkins.)

TECHNIQUE 1-33contd
into the small synovial sac beneath the meniscus, introducing a
blunt hook into it, and turning the hook so that its end rests on
the proximal surface of the meniscus. By cutting down on the
point of the hook, you can make the synovial incision at the
most distal level.

Divide the anterior attachment of the meniscus, retract the


tibial collateral ligament, and complete the excision of the
meniscus in the usual way (see Chapter 43).
When closing the incision, place the rst suture in the
synovium at the medial side near the collateral ligament while
the knee is still exed; if the joint is extended before the rst

suture is inserted, the posterior part of the synovial incision


retracts under the tibial collateral ligament. To complete the
suture line, extend the joint.

The transverse incision is not satisfactory for removing the


lateral meniscus because it would require partial division of the
iliotibial band. To avoid this, make an oblique incision 7.5 cm
long centered over the joint line (Fig. 1-50).
In the capsule, make a hockey-stick incision that runs
transversely along the joint line and curves obliquely proximally
along the anterior border of the iliotibial band for a short
distance.
Undermine and retract the capsule and incise the synovial
membrane transversely as previously described.

Lateral Approaches to the Knee and


Supporting Structures
Lateral approaches permit good exposure for complete
excision of the lateral meniscus. They do not require division or release of the bular collateral ligament.
TECHNIQUE 1-34 Bruser
Place the patient supine, and drape the limb to permit full
exion of the knee. Flex the knee fully so that the foot rests at
on the operating table.
Transverse approaches to menisci. Medial meniscus is approached through transverse incisions in skin and
capsule; lateral meniscus is approached through oblique incision in skin and hockey-stick incision in capsule.
Fig. 1-50

Begin the incision anteriorly where the patellar tendon crosses


the lateral joint line, continue it posteriorly along the joint line,
and end it at an imaginary line extending from the proximal end
of the bula to the lateral femoral condyle (Fig. 1-51A).

46

Part I General Principles

TECHNIQUE 1-34 Brusercontd

Incise the synovium. The lateral meniscus lies in the depth of


the incision and can be excised completely (Fig. 1-51C).

Incise the subcutaneous tissue and expose the iliotibial band,


whose bers are parallel with the skin incision when the knee is
fully exed (Fig. 1-51B). Split the band in line with its bers.
Posteriorly, take care to avoid injuring the relaxed bular
collateral ligament; it is protected by areolar tissue, which
separates it from the iliotibial band.

With the knee exed 90 degrees, close the synovium (Fig.


1-51D), and with the knee extended, close the deep fascia.

Brown et al. have developed an approach for lateral meniscectomy in which the knee is exed to allow important
structures to fall posteriorly as in the Bruser approach. In
addition, a varus strain is created to open the lateral joint
space.

Retract the margins of the iliotibial band; this is possible to


achieve without much force because the band is relaxed when
the knee and hip are exed.

TECHNIQUE 1-35 Brown et al.

Locate the lateral inferior genicular artery, which lies outside

Place the patient supine with the extremity straight and with a
small sandbag under the ipsilateral hip.

the synovium between the collateral ligament and the


posterolateral aspect of the meniscus.

B
Synovium

Iliotibial
band
Fibular
collateral
ligament

Popliteus
tendon

Lateral inferior
genicular artery

C
Fig. 1-51 Bruser lateral approach to knee. A, Skin incision (see text). B, Broken line indicates
proposed incision in iliotibial band, whose bers, when knee is fully exed, are parallel with
skin incision. C, Knee has been extended slightly, and lateral meniscus is being excised. D,
Lateral meniscus has been excised, and synovium is being closed. (Modied from Bruser DM:
A direct lateral approach to the lateral compartment of the knee joint, J Bone Joint Surg 42B:348,
1960.)

Chapter 1 Surgical Techniques and Approaches

47

Make a vertical, oblique, or transverse skin incision on the


anterolateral aspect of the knee.

rotate the tibia to bring the lateral tibial plateau into better view;
however, this tends to close the joint space.

Identify the anterior border of the iliotibial band, and make an


incision in the fascia 0.5 to 1 cm anterior to the band in line with
its bers.

With proper retractors, expose the entire meniscus, which can


be excised completely by sharp dissection.

Incise the synovium in line with this incision, and inspect the
joint.

TECHNIQUE 1-36

By sharp dissection, free the anterior horn of the meniscus.

Hoppenfeld and deBoer

Place the patient supine with a sandbag beneath the ipsilateral


buttock, and ex the knee 90 degrees.

Flex the knee, cross the foot over the opposite knee, and push
rmly toward the opposite hip, applying a varus force to the
knee. Ensure the thigh on the involved side is in line with the
sagittal plane of the trunk; the hip is exed about 45 degrees
and externally rotated about 40 degrees. Push, as described,
until the joint space opens up 3 to 5 mm. If necessary, internally

Begin the incision 3 cm lateral to the middle of the patella,


extend it distally over the Gerdy tubercle on the tibia, and end it
4 to 5 cm distal to the joint line. Complete the incision proximally
by curving it along the line of the femur (Fig. 1-52A).

Gerdy tubercle
Iliotibial band
Lateral patellar
retinaculum
Biceps femoris
Common peroneal
nerve

B
Posterolateral joint capsule

Iliotibial band

Biceps femoris
Lateral head of
gastrocnemius
(retracted)

Lateral femoral condyle


Synovium
Anterior joint capsule
(retracted)

Tendon of
biceps femoris
(retracted)

Lateral femoral condyle


Joint capsule

Lateral meniscus
Lateral inferior genicular artery

Tendon of
popliteus
Tibial collateral ligament

Common peroneal nerve

Fig. 1-52 Lateral approach to knee and supporting structures. A, Skin incision. B, Incision
between biceps femoris and iliotibial band. C, Deep dissection (see text). (Modied from
Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the anatomic approach, Philadelphia, 2003,
Lippincott Williams & Wilkins.)

48

Part I General Principles

TECHNIQUE 1-36

Hoppenfeld and deBoercontd

Widely mobilize the skin aps anteriorly and posteriorly.


Incise the fascia between the iliotibial band and biceps
femoris, carefully avoiding the common peroneal nerve on the
posterior aspect of the biceps tendon (Fig. 1-52B).
Retract the iliotibial band anteriorly and the biceps femoris and
common peroneal nerve posteriorly to expose the bular
collateral ligament and the posterolateral corner of the knee
capsule (Fig. 1-52C).

To expose the lateral meniscus, make a separate lateral


parapatellar incision through the fascia and joint capsule (see
Fig. 1-52B).
To avoid cutting the meniscus, begin the arthrotomy 2 cm
proximal to the joint line.

To expose the posterior horn of the lateral meniscus, locate


the origin of the lateral head of the gastrocnemius muscle on the
posterior surface of the lateral femoral condyle.
Dissect between it and the posterolateral corner of the joint
capsule; ligate or cauterize the lateral superior genicular arterial
branches located in this area.
Make a longitudinal incision in the capsule, beginning well
proximal to the joint line to avoid damaging the meniscus or
the popliteus tendon. Inspect the posterior half of the lateral
compartment posterior to the bular collateral ligament (see
Fig. 1-52C).

Extensile Approaches to the Knee


J.C. McConnell described an extensile approach to the
knee that allows access to its anterior, posterior, medial,
and lateral sides through a single incision. In addition to
excellent exposure, it leaves an unobtrusive scar. The incision has the anterior cosmesis of a typical transverse incision; it is hidden by the skin creases and is less prone to
hypertrophy than is a longitudinal incision. The medial
extension is partially hidden by the contralateral extremity,
and the lateral extension is less noticeable because it lies in
the skin depression along the posterior border of the iliotibial band.
The exposure permits the harvest and transfer of the
iliotibial band and the patellar tendon for grafts in reconstruction of ligaments; capsular reinforcement; meniscal
reattachment; and repair of intraarticular fractures of the
patella, distal femur, and medial tibial plateau. The success
of the approach is based on changes in the orientation of
the skin incision and the relative position and orientation
of the deep structures as the knee moves from exion to
extension. Any part of the incision can be used as needed.
After retraction, the deep structures are treated
appropriately.

TECHNIQUE 1-37 McConnell


With the knee in acute exion, make the transverse anterior
part of the incision between three points: the medial exion
crease, the inferior pole of the patella, and the lateral exion
crease (Fig. 1-53A).
Make the lateral extension along the posterior margin of the
iliotibial band (Fig. 1-53B). This part may be extended as far
proximally as necessary.

Make the medial extension slightly posteromedially in a distal


direction from the apex of the medial exion crease for 9 to
10 cm (Fig. 1-53C).
Incise to the fascia without subcutaneous elevation of the
skin to preserve vascularity of the skin margins. Limited sharp
dissection immediately against the fascia with the knee in
exion increases exposure of the joint capsule. The shape and
orientation of the skin incision change to a sharply angled
incision when the knee is extended (see Fig. 1-53B and C insets).

Fernandez described an extensile anterior approach to the


knee based on an anterolateral approach that allows easy
access to the medial and lateral compartments in the following ways: (1) by an extensive osteotomy of the tibial tuberosity that allows proximal reection of the patella, patellar
tendon, and retropatellar fat pad and (2) by transecting the
anterior horn and anterior portion of the coronary ligament
of the medial meniscus or the lateral meniscus or both as
necessary to achieve adequate exposure. This approach may
be used for tumor resection, ligament reconstruction, fracture reduction and xation, and adult reconstructive procedures. Part or all of this approach may be used as necessary
to achieve the required exposure. Rigid screw xation of
the tibial tuberosity engaging the posterior cortex of the
tibia allows early postoperative knee motion.
Perry et al. rst reported transection of the anterior horn
of the lateral meniscus to aid exposure of lateral tibial
plateau fractures. Healing of the lateral meniscus was documented arthroscopically in all seven knees examined in
their series. Alternatively, the articular surface of either
tibial plateau can be approached with a submeniscal exposure by releasing the peripheral attachment of the meniscus
at the coronary ligament and by elevating the meniscus, as
described by Gossling and Peterson.
TECHNIQUE 1-38 Fernandez
Place the patient supine and drape the limb to allow at least
60 degrees of knee exion.
Begin a lateral parapatellar incision 10 cm proximal to the
lateral joint line; continue it distally along the lateral border of
the patella, patellar tendon, and tibial tuberosity; and end it
15 cm distal to the lateral joint line (Fig. 1-54A).

Chapter 1 Surgical Techniques and Approaches

49

Lateral

Medial

Fig. 1-53

A-C, McConnell extensile approach to knee (see text).

Develop skin aps deep in the subcutaneous tissue extending


medially to the anterior edge of the tibial collateral ligament
and laterally, exposing the iliotibial band and the proximal
origins of the anterior tibial and peroneal muscles
(Fig. 1-54B).

Fernandez advocates an extended osteotomy into the tibial


crest in the presence of a bicondylar tibial plateau fracture to
ensure that the osteotomy fragment is securely xed into the
tibial diaphysis below the level of the fracture. A less extensive
osteotomy may be used as appropriate.

To expose the lateral tibial metaphysis, detach the anterior


tibial muscle and retract it distally, and elevate the iliotibial band
by dividing it transversely at the joint line or by performing a
at osteotomy of the Gerdy tubercle (Fig. 1-54C). If exposure of
the posteromedial portion of the tibial metaphysis is necessary,
divide the tibial insertion of the pes anserinus, or elevate it as an
osteoperiosteal ap.

Perform an extended trapezoidal osteotomy of the tibial


tuberosity as follows:
1. Mark with an osteotome a site 5 cm in length, 2 cm in width
proximally, and 1.5 cm in width distally.
2. Drill three holes for later reattachment of the tibial
tuberosity.
3. Complete the osteotomy with a at osteotome.

50

Part I General Principles

Vastus
lateralis
muscle

Vastus
medialis
muscle
Capsular
incision

Iliotibial
band
Gerdy
tubercle

Patellar
tendon

Pes
anserinus

Pes
anserinus
Outlined
osteotomy

Anterior
tibial
muscle

Medial
meniscus

Lateral
meniscus

Fig. 1-54 Fernandez extensile anterior approach. A, Anterolateral incision. B, Extensor mechanism exposed. C, Iliotibial band is reected with Gerdy tubercle. Anterior compartment and
pes anserinus are detached and elevated as necessary. Osteotomy of tibial tuberosity is outlined,
and screw holes are predrilled (see text). D, Patella, patellar tendon, and tibial tuberosity are
elevated. E, Medial and lateral menisci are detached anteriorly and peripherally and are elevated.
F, Meniscal repair is performed with 2-0 nonabsorbable sutures (see text). Gerdy tubercle is
reattached with lag screw. Anterior tibial and pes anserinus are reattached. G, Tibial tuberosity
is secured with lag screws engaging posterior cortex of tibia. Capsule is closed with interrupted
sutures. Sutures in periphery of menisci are now tied (see text). (Modied from Fernandez DL:
Anterior approach to the knee with osteotomy of the tibial tubercle for bicondylar tibial fractures, J
Bone Joint Surg 70A:208, 1988.)

Chapter 1 Surgical Techniques and Approaches

51

TECHNIQUE 1-38 Fernandezcontd


Elevate the tibial tuberosity and patellar tendon, and incise
the joint capsule transversely, medially, and laterally at the joint
line.
Carry each limb of the capsular incision proximally to the level
of the anterior border of the vastus medialis and vastus lateralis
(Fig. 1-54C and D).
If further exposure of the articular surface of the tibial plateaus
is needed, detach one or both menisci by transection of the
anterior horn, cutting the transverse ligament, and dividing the
anterior portion of the coronary ligament. The meniscus may be
elevated and held with a stay suture (Fig. 1-54E).
At wound closure, repair the anterior meniscus, coronary
ligament, and transverse ligament with 2-0 nonabsorbable
sutures. Use square stitches to repair the meniscus and two or
three U-shaped stitches to stabilize the periphery of the
meniscus.
Tie the stitches over the joint capsule after closure of the
medial and lateral arthrotomies (Fig. 1-54F).

Reattach the anterior tibial muscle and pes anserinus to bone


with interrupted sutures.
Reattach the Gerdy tubercle with a lag screw.
Rigidly x the tibial tuberosity osteotomy with lag screws
obtaining good purchase in the posterior cortex of the tibia.

Close the arthrotomy with interrupted sutures (Fig. 1-54G).

Posterior Approaches
The posterior midline approach involves structures that, if
damaged, can produce a permanent, serious disability.
Thorough knowledge of the anatomy of the popliteal space
is essential. Figure 1-55 shows the relationship of the
exion crease to the joint line, and Figure 1-56 shows
the collateral circulation around the knee posteriorly. The
approach provides access to the posterior capsule of the
knee joint, the posterior part of the menisci, the posterior
compartments of the knee, the posterior aspect of the
femoral and tibial condyles, and the origin of the posterior
cruciate ligament.
TECHNIQUE 1-39 Brackett and Osgood; Putti; Abbott
and Carpenter

Make a curvilinear incision 10 to 15 cm long over the popliteal


space (Fig. 1-57A), with the proximal limb following the tendon
of the semitendinosus muscle distally to the level of the joint.
Curve it laterally across the posterior aspect of the joint for
about 5 cm and distally over the lateral head of the
gastrocnemius muscle.
Reect the skin and subcutaneous tissues to expose the
popliteal fascia.

Fig. 1-55 Knee with Kirschner wire taped along exion


crease. Note relation of wire to joint line. Flexion crease
sags distally in elderly or obese individuals.

Identify the posterior cutaneous nerve of the calf (the medial


sural cutaneous nerve) lying beneath the fascia and between the
two heads of the gastrocnemius muscle because it is the clue to
the dissection. Lateral to it, the short saphenous vein perforates
the popliteal fascia to join the popliteal vein at the middle of the
fossa. Trace the posterior cutaneous nerve of the calf (the medial
sural cutaneous nerve) proximally to its origin from the tibial
nerve, because the contents of the fossa can be dissected
accurately and safely once this nerve is located. Trace the tibial
nerve distally and expose its branches to the heads of the
gastrocnemius, the plantaris, and the soleus muscles; these
branches are accompanied by arteries and veins. Follow the tibial
nerve proximally to the apex of the fossa where it joins the
common peroneal nerve (Fig. 1-57B). Dissect the common
peroneal nerve distally along the medial border of the biceps
muscle and tendon, and protect the lateral cutaneous nerve of
the calf and the anastomotic peroneal nerve.
Expose the popliteal artery and vein, which lie directly anterior
and medial to the tibial nerve. Gently retract the artery and
vein and locate and trace the superolateral and superomedial
genicular vessels passing beneath the hamstring muscles on
either side just proximal to the heads of origin of the
gastrocnemius (see Fig. 1-56).

Open the posterior compartments of the joint with the knee


extended and explore them with the knee slightly exed. The
medial head of the gastrocnemius arises at a more proximal level
from the femoral condyle than does the lateral head, and the
groove it forms with the semimembranosus forms a safe and
comparatively avascular approach to the medial compartment
(Fig. 1-57C). Turn the tendinous origin of the medial head of the

52

Part I General Principles

Biceps femoris
muscle
Superior medial
genicular artery
Medial head of
gastrocnemius muscle
Fig. 1-56

Collateral circulation around knee

posteriorly.

Tendon of
semimembranosus
muscle
Inferior medial
genicular artery
Popliteus muscle

Superior lateral
genicular artery
Lateral head of
gastrocnemius muscle
Common peroneal
nerve
Inferior lateral
genicular artery

Tibial nerve
Soleus muscle

TECHNIQUE 1-39 Brackett and Osgood; Putti; Abbott


and Carpentercontd

Isolate the lateral cutaneous nerve of the calf, retract it


laterally, and preserve it.

gastrocnemius laterally to serve as a retractor for the popliteal


vessels and nerves (Fig. 1-57D).

Identify the short saphenous vein supercial to the fascia and

Greater access can be achieved by ligating one or more


genicular vessels. If the posterolateral aspect of the joint is to be
exposed, elevate the lateral head of the gastrocnemius muscle
from the femur, and approach the lateral compartment between
the tendon of the biceps femoris and the lateral head of the
gastrocnemius muscle.

Open the fascia carefully in line with the incision. The sural
nerve lies deep to the fascia just supercial to the heads of
the gastrocnemius muscle and must be protected (Fig.
1-58A).

When closing the wound, place interrupted sutures in the

Develop the interval between the lateral head of the


gastrocnemius and the soleus muscles, and retract the lateral
head of the gastrocnemius medially.

capsule, the deep fascia, and the skin. The popliteal fascia is best
closed by placing all sutures before drawing them tight. Tie the
sutures one by one.

Minkoff, Jaffe, and Menendez described a limited posterior approach to the proximal lateral tibia and knee. It
uses the interval between the popliteus and soleus muscles
and exposes the uppermost lateral portion of the posterior
tibial metaphysis and the proximal tibiobular joint.
Although this approach was developed to excise an osteoid
osteoma from the lateral tibial plateau, it can be used for
other conditions affecting the posterior aspect of the
knee.
TECHNIQUE 1-40 Minkoff, Jaffe, and Menendez
Begin the skin incision 1 to 2 cm below the popliteal crease
slightly medial to the midline of the knee, carrying it transversely
and curving it distally just medial and parallel to the head of the
bula, ending 5 to 6 cm distal to it.

Reect the skin and subcutaneous ap inferomedially.

divide and ligate it.

Identify the common peroneal nerve and retract it laterally.

Retract the popliteal artery and vein and the tibial nerve
along with the lateral head of the gastrocnemius (Fig. 1-58B).
Dissect free the bular origin of the soleus muscle and retract
it distally.
Retract the underlying popliteus muscle medially to expose the
posterior aspect of the lateral tibial plateau and proximal
tibiobular joint (Fig. 1-58C).

Femur
Anterolateral Approach
The anterolateral approach exposes the middle third of the
femur, but postoperative adhesions between the individual
muscles of the quadriceps group and between the vastus
intermedius and the femur may limit knee exion. The
quadriceps mechanism must be handled gently. Infections
of the middle third of the shaft are best approached posterolaterally. When the shaft must be approached from the
medial side, this anterolateral approach, rather than an
anteromedial one, is indicated.

Chapter 1 Surgical Techniques and Approaches

Deep
fascia
of the
thigh

Common
peroneal
nerve
Semimembranosus
muscle

Tibial nerve

Lateral sural
cutaneous nerve

Popliteal
fascia
Medial head of
gastrocnemius
muscle
Medial sural
cutaneous
nerve

Communicating
branch of
peroneal nerve
Lateral head of
gastrocnemius
muscle

External
saphenous vein

B
Semimembranosus
muscle

Sciatic nerve

Superior
medial
genicular
artery

Tibial nerve
Posterior
capsule of
knee joint

Medial head of
gastrocnemius
muscle

Oblique
popliteal
ligament

Biceps femoris
muscle

Division of
medial head of
gastrocnemius
muscle
Medial head of
gastrocnemius
muscle turned
laterally

Medial sural
cutaneous nerve

D
Fig. 1-57 Posterior approach to knee joint. A, Posterior curvilinear incision. Posterior cutaneous nerve of calf exposed and retracted. B, Sciatic nerve and its division dened. C, Medial
head of gastrocnemius muscle exposed. D, Tendon of origin of medial head of gastrocnemius
muscle divided, exposing capsule of knee joint. If further exposure is necessary, lateral head
of gastrocnemius is dened, incised, and retracted in similar fashion.

53

54

Part I General Principles

Medial

Lateral

Common
peroneal
nerve
Sural
nerve

Soleus
muscle

Lateral head of
gastrocnemius
muscle

Gastrocnemius-soleus
interval

Inferior lateral
genicular vessels
Common
peroneal
nerve
Proximal
tibiofibular
joint

Lateral
head of
gastrocnemius
muscle

Popliteal
vessels
Popliteus
muscle
(retracted)

Reflected soleus
muscle

Tibia

Fig. 1-58 Minkoff, Jaffe, and Menendez posterolateral approach. A, Supercial dissection. B,
Gastrocnemius and popliteal vessels are retracted medially, and bular origin of soleus is
reected distally. C, Popliteus is retracted medially exposing posterior aspect of tibial plateau
and proximal tibiobular joint. (Modied from Minkoff J, Jaffe L, Menendez L: Limited posterolateral surgical approach to the knee for excision of osteoid osteoma, Clin Orthop 223:237, 1987.)

TECHNIQUE 1-41

Thompson

Incise the skin over the middle third of the femur in a line
between the anterior superior iliac spine and the lateral margin
of the patella (Fig. 1-59).

Incise the supercial and deep fasciae, and separate the


rectus femoris and vastus lateralis muscles along their
intermuscular septum. The vastus intermedius muscle is brought
into view.

Divide the vastus intermedius muscle in the line of its bers


down to the femur.

Expose the femur by subperiosteal reection of the incised


vastus intermedius muscle.

Henry exposes the entire femoral shaft by extending this


incision proximally and distally. The approach is not recommended for operations on the proximal third of the
femur because exposing the bone here is difcult without
injuring the lateral femoral circumex artery and the nerve
to the vastus lateralis muscle. Distally, the incision may be
extended to within 12 to 15 cm of the knee joint; at this
point, however, the insertion of the vastus lateralis muscle

Chapter 1 Surgical Techniques and Approaches

55

Lateral femoral
circumflex artery

Nerve to vastus
lateralis muscle

Vastus lateralis muscle


Rectus femoris muscle
Vastus intermedius muscle
Rectus femoris
muscle
Incision

Vastus lateralis muscle

Vastus
intermedius
muscle

Fig. 1-59 Anterolateral approach to femur. A, Skin incision. B, Femur exposed by separation
of rectus femoris and vastus lateralis muscles and division of vastus intermedius muscle.

into the quadriceps tendon is encountered, as is the more


distal suprapatellar bursa.
Lateral Approach
Anatomically, the entire femoral shaft may be exposed by
the lateral approach, but only its less extensive forms are
recommended. The posterolateral approach is preferred
whenever possible to avoid splitting the vastus lateralis.
TECHNIQUE 1-42
Make an incision of the desired length over the lateral aspect
of the thigh along a line from the greater trochanter to the
lateral femoral condyle (Fig. 1-60A).
Incise the supercial and deep fasciae.
Divide the vastus lateralis and vastus intermedius muscles in
the direction of their bers, and open and reect the periosteum
for the proper distance.
A branch of the lateral femoral circumex artery is
encountered when exposing the proximal fourth of the femur
and the superior lateral genicular artery in the distal fourth; these
may be clamped, divided, and ligated without harm.

Posterolateral Approach
The posterolateral approach provides access to the entire
femoral shaft.

TECHNIQUE 1-43
Turn the patient slightly to elevate the affected side.
Make the incision from the base of the greater trochanter
distally to the lateral condyle (Fig. 1-60B).
Incise the supercial fascia and fascia lata along the anterior
border of the iliotibial band.

Expose the posterior part of the vastus lateralis muscle and


retract it anteriorly (in muscular individuals this retraction may be
difcult); continue the dissection down to bone along the
anterior surface of the lateral intermuscular septum, which is
attached to the linea aspera.
Retract the deep structures, and split the periosteum in the
line of the incision.
With a periosteal elevator, free the attachment of the vastus
intermedius muscle as far as necessary.

56

Part I General Principles

Vastus
lateralis
muscle
Periosteum

Anterior
aspect of
intermuscular
septum

Vastus
lateralis
muscle

Vastus intermedius
muscle

Cross
section
here

Vastus
lateralis
muscle

Rectus femoris
muscle

A
A
B

Fig. 1-60 Posterolateral and lateral approaches to middle third of femur. Lateral approach (A).
Vastus lateralis and vastus intermedius have been incised in line with their bers. Cross section
shows these approaches. Posterolateral approach (B) along lateral intermuscular septum.

TECHNIQUE 1-43contd
In the middle third of the thigh, the second perforating branch
of the profunda femoris artery and vein run transversely from the
biceps femoris to the vastus lateralis. Ligate and divide these
vessels.
To avoid damaging the sciatic nerve and the profunda femoris
artery and vein, do not separate the long and short heads of the
biceps femoris muscle.

Posterior Approach

TECHNIQUE 1-44

Bosworth

With the patient prone, incise the skin and deep fascia
longitudinally in the middle of the posterior aspect of the thigh,
from just distal to the gluteal fold to the proximal margin of the
popliteal space.

Chapter 1 Surgical Techniques and Approaches

Sciatic nerve

Femur

Long head of
biceps femoris
muscle

Vastus lateralis
muscle
Sciatic
nerve

57

Short head of biceps


femoris muscle
Femur
Long head of biceps
femoris muscle

Semitendinosus
muscle
Sciatic
nerve

Long head
of biceps
femoris
muscle

Long head of
biceps femoris
muscle

Vastus lateralis
muscle
Linea aspera
Short head
of biceps
femoris muscle

Short head of
biceps femoris
muscle

Semimembranosus
muscle
Sciatic nerve

D
Fig. 1-61 Bosworth posterior approach to femur. A, To expose proximal part of middle three
fths of femur, long head of biceps femoris has been retracted medially. Inset, Skin incision.
B, To expose distal part of middle three fths of femur, long head of biceps femoris and sciatic
nerve have been retracted laterally. C, To expose entire middle three fths of femur, long head
of biceps femoris has been divided in distal part of wound, and this muscle and sciatic nerve
have been retracted medially. D, Sciatic nerve would be subject to injury if entire middle three
fths of femur were exposed by retracting biceps femoris laterally.

Use the long head of the biceps as a guide. By blunt dissection


with the index nger, palpate the posterior surface of the femur
at the middle of the thigh. To expose the middle three fths of
the linea aspera, use the ngers to retract the attachment of the
vastus medialis and lateralis muscles.
To expose the proximal part of the middle three fths of the
femur, continue the blunt dissection along the lateral border of
the long head of the biceps, developing the fascial plane

between the long head of the biceps and the vastus lateralis
muscle, and reect the long head of the biceps medially (Fig.
1-61A).

To expose the distal part of the middle three fths of the


femur, carry the dissection along the medial surface of the long
head of the biceps, developing the fascial plane between the
long head of the biceps and the semitendinosus, and retract the
long head of the biceps and the sciatic nerve laterally (Fig. 1-61B).

58

Part I General Principles

TECHNIQUE 1-44

Bosworthcontd

To expose the entire middle three fths of the femur, carry the
blunt dissection to the linea aspera lateral to the long head of
the biceps, divide the latter muscle in the distal part of the
wound, and displace it medially, together with the sciatic nerve
(Fig. 1-61C).
Part of the nerve supply to the short head of the biceps
crosses the exposure near its center; this branch of the sciatic
nerve may be saved or divided, depending on the requirements
of the incision because it does not make up the entire nerve
supply of this part of the biceps.
After exposing the linea aspera, free the muscle attachments
by sharp dissection, and expose the femur by subperiosteal
dissection.

Bosworth points out that the entire middle three fths of the
femur should never be exposed by retracting the long head of
the biceps and sciatic nerve laterally because this unnecessarily
endangers the sciatic nerve (Fig. 1-61D).
When the distal end of the long head of the biceps is to be
divided, place sutures in the distal segment of the muscle before
the division is carried out; this makes suturing the muscle easier
when the wound is being closed.

After suturing the biceps, close the wound by suturing only


the skin and subcutaneous tissue because the other structures
fall into position.
When developing this approach, the surgeon must keep in
mind the possibility of damaging the sciatic nerve. Rough
handling and prolonged or strenuous retraction of the nerve may
cause distressing symptoms after surgery or possibly a permanent
disability in the leg.

Medial Approach to the Posterior Surface of the


Femur in the Popliteal Space
When possible, the medial approach should be used in
preference to an anteromedial approach because in the
latter the vastus medialis must be separated from the rectus
femoris, and the vastus intermedius must be split.
TECHNIQUE 1-45

Henry

With the knee slightly exed, begin the incision 15 cm


proximal to the adductor tubercle, and continue it distally along
the adductor tendon, following the angle of the knee to 5 cm
distal to the tubercle (Fig. 1-62A).
In the distal part of the incision, carry the dissection

the adductor magnus muscle. Protect the saphenous nerve,


which follows the sartorius on its deep surface; the great
saphenous vein is supercial and is not in danger if the incision is
made properly.

Divide the thin fascia posterior to the adductor tendon by


blunt dissection to the posterior surface of the femur at the
popliteal space.
Retract the large vessels and nerves posteriorly; branches
from the muscles to the bone may be isolated, clamped, and
divided.
Retract the adductor magnus tendon and a part of the vastus
medialis muscle anteriorly, and expose the bone. The tibial and
common peroneal nerves are not encountered, because they lie
lateral and posterior to the line of incision.

Checroun et al. proposed an extensile medial approach


to the femur after an extensive cadaver study. The interval
between the vastus medialis and adductor muscles is used
and allows exposure from the medial femoral condyle to
as far proximal as the lesser trochanter. Their original work
should be reviewed before attempting this approach. We
have no experience with it at present.
Lateral Approach to the Posterior Surface of the
Femur in the Popliteal Space
TECHNIQUE 1-46 Henry
With the knee slightly exed, incise the skin and supercial
fascia for 15 cm along the posterior edge of the iliotibial band,
and follow the angle of the knee to the head of the bula
(Fig. 1-62B).

Divide the deep fascia immediately posterior to the iliotibial


band.

Just proximal to the condyle, separate the attachment of the


short head of the biceps from the posterior surface of the lateral
intermuscular septum; reach the popliteal space by blunt
dissection between these structures.
Ligate and divide the branches of the perforating vessels and
retract the popliteal vessels posteriorly in the posterior wall of
the wound. The tibial nerve lies posterior to the popliteal vessels,
and the common peroneal nerve follows the medial edge of the
biceps.
Expose the surface of the femur by incising and elevating the
periosteum.

posteriorly to the anterior edge of the sartorius muscle just


proximal to the level of the adductor tubercle.

Free the deep fascia proximally over this muscle, taking


care to avoid puncturing the synovial membrane, which is
beneath the muscle when the joint is exed. After this
procedure, the sartorius falls posteriorly, exposing the tendon of

Lateral Approach to the Proximal Shaft and the


Trochanteric Region
The lateral approach is excellent for reduction and internal
xation of trochanteric fractures or for subtrochanteric
osteotomies under direct vision.

Chapter 1 Surgical Techniques and Approaches

Vastus medialis muscle

59

Lateral intermuscular septum

Adductor magnus tendon

Biceps
muscle

Sartorius
muscle

Popliteal
space
Popliteal
artery

Popliteal space

Fig. 1-62 Henry medial and lateral approaches to posterior surface of femur in popliteal space.
A, Medial approach. B, Lateral approach.

TECHNIQUE 1-47
Begin the incision about 5 cm proximal and anterior to the
greater trochanter, curving it distally and posteriorly over the
posterolateral aspect of the trochanter and distally along the
lateral surface of the thigh, parallel with the femur, for 10 cm or
more, depending on the desired exposure (see Fig. 1-61B).
Deepen the dissection in the line of the incision down to the
fascia lata.
In the distal part of the wound, incise the fascia lata with a
scalpel and split it proximally with scissors. In the proximal part
of the wound, divide the fascia just posterior to the tensor
fasciae latae muscle to avoid splitting this muscle.
By retraction bring into view the vastus lateralis muscle and its
origin from the inferior border of the greater trochanter. Divide
the origin of the muscle transversely along this border down to
the posterolateral surface of the femur.

Divide the vastus lateralis and its fascia longitudinally with


scissors, beginning on its posterolateral surface, 0.5 cm from its
attachment to the linea aspera.

Alternatively, rst split the muscle fascia alone laterally instead


of posterolaterally, dissect the muscle from its deep surface
posteriorly, and divide the muscle near the linea aspera (closing
the fascia lata then is easier). The muscle is divided where it is
thin rather than thick, as is necessary in a direct lateral musclesplitting approach (Fig. 1-63A and C). Section no more than
0.5 cm of the muscle at one time. Keep the body of the vastus
retracted anteriorly; by this means, if one of the perforating
arteries is divided, it may be clamped and tied before it retracts
beyond the linea aspera.
After dividing the muscle along the femur for the required
distance, elevate it with a periosteal elevator, and expose the
lateral and anterolateral surfaces of the femoral shaft (Fig. 1-63D).
By further subperiosteal elevation of the proximal part of the
vastus lateralis and intermedius muscles, expose the
intertrochanteric line and the anterior surface of the femur just
below this line.
The base of the femoral neck may be exposed by dividing the
capsule of the joint at its attachment to the intertrochanteric
line.

60

Part I General Principles

Tensor fasciae
latae muscle

Incision

B
Vastus
lateralis
muscle

A
Tensor fasciae
latae muscle
Vastus
lateralis
muscle
Incision

D
Fig. 1-63 Lateral approach to proximal shaft and trochanteric region of femur. A, Cross section
shows level of approach at lesser trochanter. B, Fascia lata has been incised in line with skin
incision. Vastus lateralis has been incised transversely just distal to greater trochanter and is
being incised longitudinally 0.5 cm from linea aspera. Inset, Skin incision. C, Cross section
shows approach at level of distal end of skin incision. D, Approach has been completed by
dissecting vastus lateralis subperiosteally from femur. Hip joint may be exposed by continuing
approach proximally as in Watson-Jones approach.

TECHNIQUE 1-47contd
If a wider exposure is desired, elevate the distal part of the

Anterior Approaches
Smith-Petersen improved and revived interest in the anterior iliofemoral approach, and now it is used often.

gluteus minimus from its insertion on the trochanter.

In closure, the vastus lateralis muscle falls over the lateral

TECHNIQUE 1-48

surface of the femur. Suture the fascia lata and close the
remainder of the wound routinely.

Begin the incision at the middle of the iliac crest or, for a
larger exposure, as far posteriorly on the crest as desired. Carry it
anteriorly to the anterior superior iliac spine and distally and
slightly laterally 10 to 12 cm (Fig. 1-64).

Hip
Numerous new approaches to the hip have been described
since the 1990s; most are based on older approaches and
are modied for a specic surgical procedure. In this
section, the general approaches that we have found most
useful are described. The specic approaches used in revision total hip arthroplasty are described in Chapter 7.

Smith-Petersen

Divide the supercial and deep fasciae, and free the


attachments of the gluteus medius and the tensor fasciae latae
muscles from the iliac crest.
With a periosteal elevator, strip the periosteum with the
attachments of the gluteus medius and minimus muscles from
the lateral surface of the ilium. Control bleeding from the

Chapter 1 Surgical Techniques and Approaches

nutrient vessels by packing the interval between the ilium and


the reected muscles.

Carry the dissection through the deep fascia of the thigh and
between the tensor fasciae latae laterally and the sartorius and
rectus femoris medially.

Clamp and ligate the ascending branch of the lateral femoral


circumex artery, which lies 5 cm distal to the hip joint.

The lateral femoral cutaneous nerve passes over the sartorius


2.5 cm distal to the anterior superior spine; retract it to the
medial side.
If the structures at the anterior superior spine are contracted,
free the spine with an osteotome, and allow it to retract with its
attached muscles to a more distal level.
Expose and incise the capsule transversely and reveal the
femoral head and the proximal margin of the acetabulum. The
capsule also may be sectioned along its attachment to the
acetabular labrum (cotyloid ligament) to give the required
exposure.
If necessary, the ligamentum teres may be divided with a
curved knife or with scissors and the femoral head dislocated,
giving access to all parts of the joint.

Nearly all surgery of the hip joint may be carried out


through this approach, or separate parts can be used for

different purposes. The anterior femoral incision exposes


the joint but is inadequate for reconstructive operations.
The entire ilium and hip joint can be reached through the
iliac part of the incision; all structures attached to the iliac
crest from the posterior superior iliac spine to the anterior
superior iliac spine are freed and are reected from the
lateral surface of the ilium; dissection is carried distally to
the anterior inferior iliac spine. Smith-Petersen also modied and improved this approach for extensive surgery of
the hip by reecting the iliacus muscle from the medial
surface of the anterior part of the ilium and by detaching
the rectus femoris muscle from its origin.
Schaubel modied the Smith-Petersen anterior approach
after nding reattachment of the fascia lata to the fascia on
the iliac crest difcult. Instead of dividing the fascia lata at
the iliac crest, an osteotomy of the overhang of the iliac
crest is performed between the attachments of the external
oblique muscle medially and the fascia lata. The osteotomy
may be carried posteriorly as far as the origin of the gluteus
maximus. The tensor fasciae latae, gluteus medius, and
gluteus minimus muscle attachments are subperiosteally dissected distally to expose the hip joint capsule. The abductors and short external rotators may be dissected from the
greater trochanter as necessary for total hip arthroplasty,
prosthetic replacement of the femoral head, or arthrodesis
of the hip. At closure, the iliac osteotomy fragment is
reattached with 1-0 or 2-0 nonabsorbable sutures passed
through holes drilled in the fragment and the ilium.

Gluteus medius muscle


Ilium

Tensor fasciae latae muscle

Sartorius
muscle

Skin incision

Gluteus
maximus
muscle

Iliotibial
band

Tensor fasciae
latae muscle
Head and
neck of
femur

Sartorius
muscle
Rectus femoris
muscle

61

B
Fig. 1-64 Smith-Petersen anterior iliofemoral approach to hip. A, Line of skin incision. B,
Exposure of joint after reection of tensor fasciae latae and gluteal muscles from lateral surface
of ilium and division of capsule.

62

Part I General Principles

Somerville described an anterior approach using a transverse bikini incision for irreducible congenital dislocation of the hip in a young child. This approach allows
sufcient exposure of the ilium, and access to the acetabulum is satisfactory even when it is in an abnormal location.
For reduction of a congenitally dislocated hip, the following sequential steps must be performed: psoas tenotomy,
complete medial capsulotomy including the transverse acetabular ligament, excision of hypertrophied ligamentum
teres, and reduction of the femoral head into the true
acetabulum. Specic indications and postsurgical care for
congenital dislocation of the hip are discussed in Chapter
27.
TECHNIQUE 1-49

Make a straight skin incision, beginning anteriorly inferior and


medial to the anterior superior spine and coursing obliquely
superiorly and posteriorly to the middle of the iliac crest (Fig. 165A). Deepen the incision to expose the crest.

Reect the abductor muscles subperiosteally from the iliac


wing distally to the capsule of the joint. Increase exposure of the
capsule by separating the tensor fasciae latae from the sartorius
for about 2.5 cm inferior to the anterior superior spine.

Expose the reected head of the rectus femoris, and separate


it from the acetabulum and capsule, leaving the straight head
attached to the anterior inferior spine (Fig. 1-65B). The straight
head may be detached to increase exposure.
Near the acetabular rim, make a small incision in the capsule,
and extend it anteriorly to a point deep to the rectus and
posteriorly to the posterosuperior margin of the joint
(Fig. 1-65C).

Somerville

Place a sandbag beneath the affected hip.

Iliopsoas tendon
Sartorius muscle
Rectus femoris muscle

Fig. 1-65 Somerville technique of open reduction. A, Bikini incision. B, Division of sartorius
and rectus femoris tendons and iliac epiphysis. C, T incision of capsule. D, Capsulotomy of hip
and use of ligamentum teres to nd true acetabulum. E, Radial incisions in acetabular labrum
and removal of all tissue from depth of true acetabulum. F, Capsulorrhaphy after excision of
redundant capsule.

Chapter 1 Surgical Techniques and Approaches

Exert enough traction on the limb to distract the cartilage of


the femoral head from that of the acetabulum about 0.7 cm.

Examine the inside of the acetabulum visually (Fig. 1-65D). If


no inverted limbus is seen, insert a blunt hook, and palpate the
joint for the free edge of an inverted limbus. If one is found,
place the tip of the hook deep to the limbus and force it through
its base; separate from its periphery that part of the limbus lying
anterior to the hook until the hook comes out.
With Kocher forceps, grasp the limbus by the end thus freed
and excise it with strong curved scissors, or make radial T-shaped
incisions to evert the limbs and allow reduction of the femoral
head (Fig. 1-65E).
Reduce the head into the acetabulum by abducting the thigh
30 degrees and internally rotating it. Hold the joint in this
position and close the capsule (Fig. 1-65F).
Reattach the muscles to the iliac crest, close the skin, and
apply a spica cast.

63

Inferiorly carry the fascial incision across the insertion of the


tensor fasciae latae into the iliotibial band, and expose the lateral
part of the rectus femoris and the anterior part of the vastus
lateralis muscles.
Begin the capsular incision on the inferior aspect of the
capsule just lateral to the acetabular labrum; from this point,
extend it proximally, parallel with the acetabular labrum, to the
superior aspect of the capsule, and curve it laterally, continuing
on beyond the capsule to the base of the greater trochanter. This
incision divides that part of the reected head of the rectus
femoris that blends into the capsule inferior to its insertion into
the superior margin of the acetabulum. By reecting it with the
capsule, the capsular ap is reinforced, and repair is made easier.

Lateral Approaches
TECHNIQUE 1-51

Watson-Jones

Begin an incision 2.5 cm distal and lateral to the anterior

Anterolateral Approach
Smith-Petersen described a modication of the anterior
iliofemoral approach that he used for open reduction and
internal xation of fractures of the femoral neck. This
approach retains the advantages of the anterior iliofemoral
approach but exposes the trochanteric region laterally; this
makes aligning a fracture or osteotomy of the femoral neck
and inserting pins or nails under direct vision easier. This
approach also is useful in reconstructive procedures such as
osteotomy for slipping of the proximal femoral epiphysis
and procedures for nonunions of the femoral neck. It gives
a continuous exposure of the anterior aspect of the hip
from the acetabular labrum to the base of the trochanter.
TECHNIQUE 1-50

superior iliac spine and curve it distally and posteriorly over the
lateral aspect of the greater trochanter and lateral surface of the
femoral shaft to 5 cm distal to the base of the trochanter (Fig.
1-66).

Locate the interval between the gluteus medius and tensor


fasciae latae. The delineation of this interval often is difcult.
Brackett pointed out that it can be done more easily by
beginning the separation midway between the anterior superior
spine and the greater trochanter, before the tensor fasciae latae
blends with its fascial insertion. The coarse grain and the
direction of the bers of the gluteus medius help to distinguish
them from the ner structure of the tensor fasciae latae muscle.

Smith-Petersen

Make the skin incision along the anterior third of the iliac crest
and along the anterior border of the tensor fasciae latae muscle;
curve it posteriorly across the insertion of this muscle into the
iliotibial band in the subtrochanteric region (usually at a point 8
to 10 cm below the base of the greater trochanter) and end it
there.

A
Tensor fasciae
latae muscle

Incise the fascia along the anterior border of the tensor fasciae
latae muscle. Identify and protect the lateral femoral cutaneous
nerve, which usually is medial to the medial border of the tensor
fasciae latae and close to the lateral border of the sartorius.

Cleanly incise the muscle attachments to the lateral aspect of


the ilium along the iliac crest to make reection of the
periosteum easier. Reect it as a continuous structure, without
fraying, distally to the superior margin of the acetabulum.
Divide the muscle attachments between the anterior superior
iliac spine and the acetabular labrum. The ap thus reected
consists of the tensor fasciae latae, the gluteus minimus, and the
anterior part of the gluteus medius.

Gluteus medius
muscle

Vastus lateralis
muscle

Fig. 1-66 Watson-Jones lateral approach to hip joint. A,


Skin incision. B, Approach has been completed except for
incision of joint capsule.

64

Part I General Principles

requires an osteotomy of the greater trochanter, however,


with the resulting risk of nonunion or trochanteric bursitis.
Also, as reported by Testa and Mazur, the incidence of
signicant or disabling heterotopic ossication is increased
after total hip arthroplasty using a transtrochanteric lateral
approach compared with a direct lateral approach.

TECHNIQUE 1-51 Watson-Jonescontd


Carry the dissection proximally to expose the inferior branch of
the superior gluteal nerve, which innervates the tensor fasciae
latae muscle.

Incise the capsule of the joint longitudinally along the


anterosuperior surface of the femoral neck. In the distal part of
the incision, the origin of the vastus lateralis may be reected
distally or split longitudinally to expose the base of the
trochanter and proximal part of the femoral shaft.

TECHNIQUE 1-52

Harris

Place the patient on the unaffected hip, and elevate the


affected one 60 degrees; maintain this position by using
sandbags or a long thick blanket roll extending from beneath the
scapula to the sacrum.

If a wider eld is desired, detach the anterior bers of the


gluteus medius tendon from the trochanter or reect the
anterosuperior part of the greater trochanter proximally with an
osteotome, together with the insertion of the gluteus medius
muscle. This preserves the insertion of the gluteus medius in
such a way that it can be easily reattached later.

Make a U-shaped skin incision, with its base at the posterior


border of the greater trochanter as follows (Fig. 1-67A). Begin
the incisision about 5 cm posterior and slightly proximal to the
anterior superior iliac spine, curve it distally and posteriorly to the
posterosuperior corner of the greater trochanter, extend it
longitudinally for about 8 cm, and nally curve it gradually
anteriorly and distally, making the two limbs of the U
symmetrical.

Harris recommends the following lateral approach for


extensive exposure of the hip. It permits dislocation of the
femoral head anteriorly and posteriorly. This approach

Vastus intermedius
muscle

Gluteus
medius
muscle
Vastus lateralis
muscle

Gluteus
maximus
muscle

Fascia lata

Greater trochanter

Vastus lateralis
muscle origin
reflected

Gluteus
medius
muscle
Gluteus
maximus
muscle

Greater trochanter

Fig. 1-67 Harris lateral approach to hip. A, Iliotibial band has been divided proximal to greater
trochanter. A nger has been placed on insertion of gluteus maximus deep to band, and fascia
lata is to be incised 1 ngerbreadth anterior to insertion (broken line) without cutting into insertion of gluteus maximus. B, To obtain wide exposure posteriorly and to provide space into
which femoral head can be dislocated, short oblique incision has been made in posteriorly
reected fascia lata, extending into gluteus maximus (see text). Greater trochanter is to be
osteotomized (see text).

Chapter 1 Surgical Techniques and Approaches

65

femoral head can be dislocated, make a short oblique incision in


the deep surface of the posteriorly reected fascia lata,
extending into the substance of the gluteus maximus (see Fig. 167A). Begin this incision at the level of the middle of the greater
trochanter, and extend it medially and proximally into the gluteus
maximus parallel to its bers for 4 cm.

Beginning distally, divide the iliotibial band in line with the skin
incision; at the greater trochanter, place a nger deep to the
band, feel the femoral insertion of the gluteus maximus on the
gluteal tuberosity, and guide the incision in the fascia lata
posteriorly, but stay one ngerbreadth anterior to this insertion.

Continue the incision in the fascia lata proximally in line with

Reect anteriorly the anterior part of the iliotibial band

the skin incision, releasing the fascia overlying the gluteus


medius.

and the tensor fasciae latae, which form the anterior ap,
passing a periosteal elevator along the anterior capsule to the
acetabulum.

Exposure of the posterior aspect of the greater trochanter, the


insertion of the short external rotators, and the posterior part of
the joint capsule is limited by the posterior part of the fascia lata
and the gluteus maximus bers that insert into it. To obtain wide
exposure posteriorly and to provide a space into which the

Free the abductor muscles by osteotomizing the greater


trochanter as follows (Fig. 1-67B): Reect distally the origin of
the vastus lateralis; place an instrument between the abductor

Gluteus medius
muscle
Gluteus minimus
muscle
Osteotomized
greater trochanter
Obturator externus muscle

Obturator internus muscle


Piriformis muscle

Iliopsoas muscle

Acetabulum
Iliopsoas muscle

Osteotomized
greater trochanter
placed in acetabulum

Femoral head dislocated


posterior to acetabulum
Fig. 1-67, contd C, Greater trochanter has been osteotomized and retracted superiorly; superior
part of joint capsule has been freed; and insertions of piriformis, obturator externus, and obturator internus are to be divided. D, Full circumference of femoral head has been exposed by
placing greater trochanter and its muscle pedicle into acetabulum and externally rotating femur.
E, Entire acetabulum has been exposed by retracting greater trochanter superiorly and dislocating femoral head posteriorly.

66

Part I General Principles

TECHNIQUE 1-52 Harriscontd

TECHNIQUE 1-53 McFarland and Osborne

muscles and the superior surface of the joint capsule, and direct
the osteotomy superiorly and medially from a point 1.5 cm distal
to the tubercle of the vastus lateralis to the superior surface of
the femoral neck.

Make a midlateral skin incision (Fig. 1-68A) centered over the


greater trochanter; its length depends on the amount of
subcutaneous fat. Expose the gluteal fascia and the iliotibial
band, and divide them in a straight midlateral line along the
entire length of the skin incision (Fig. 1-68B).

Free the superior part of the joint capsule from the greater
trochanter. During these maneuvers, protect the sciatic nerve by
using a smooth retractor.
1. Divide the piriformis, obturator externus, and obturator
internus at their femoral insertions (Fig. 1-67C).
2. Excise the anterior and posterior parts of the capsule under
direct vision as far proximally as the acetabulum.
Proceed with the operation anteriorly. Deep to the rectus
femoris insert a small, blunt-pointed Bennett retractor so that its
hook is placed over the anterior inferior iliac spine.

Reect superiorly the greater trochanter and its attached


abductor muscles to expose the superior and anterior parts of
the capsule.
Place a thin retractor between the capsule and the iliopsoas to

Retract the gluteus maximus posteriorly and the tensor fasciae


latae anteriorly.
Expose the gluteus medius, and separate it from the piriformis
and gluteus minimus by blunt dissection.

Identify the prominent posterior border of the gluteus medius


where it joins the posterior edge of the greater trochanter. From
this point, make an incision down to the bone through the
periosteum and fascia obliquely and distally across the greater
trochanter to the middle of the lateral aspect of the femur;
continue it further distal in the vastus lateralis to the distal end
of the skin incision (Fig. 1-68C).

With a knife or a sharp chisel, peel from the bone, in one

expose the anterior and inferior parts of the capsule. Working


from the anterior and posterior aspects of the joint, excise as
much of the capsule as desired; if the iliopsoas muscle is to be
transplanted, leave the stump of the anterior part of the capsule
intact.

piece, the attachment of the gluteus medius, the periosteum, the


tendinous junction of the gluteus medius and vastus lateralis, and
the origin of the vastus lateralis. The portion of the vastus
lateralis peeled off includes that attached to the proximal part of
the linea aspera, the distal border of the greater trochanter, and
part of the shaft of the femur.

Dislocate the femoral head anteriorly by extending, adducting,


and externally rotating the femur. Before or after the hip has
been dislocated, bring the lesser trochanter into view by exing
and externally rotating the femur and, if desired, divide the
iliopsoas under direct vision.

Anteriorly retract the whole combined muscle mass, consisting


of the gluteus medius and vastus lateralis with their tendinous
junction (Fig. 1-68D). Split, divide, and proximally retract the
tendon of the gluteus minimus to expose the capsule of the hip
joint (Fig. 1-68E). Incise the capsule as desired (Fig. 1-68F).

Expose the full circumference of the femoral head by placing


the greater trochanter and its muscle pedicle into the acetabulum
and externally rotating the femur (Fig. 1-67D).

During closure, suture the capsule and gluteus minimus as one

To expose the entire acetabulum, retract the greater trochanter


superiorly, and dislocate the femoral head
posteriorly (Fig. 1-67E) by exing the knee and adducting,
exing, and internally rotating the hip. Flexing the knee reduces
tension on the sciatic nerve while the head is dislocated
posteriorly.
When closing the wound, position the limb in almost full
abduction and in about 10 degrees of external rotation.
Transplant the greater trochanter distally, and x it directly to the
lateral side of the femoral shaft with two wire loops or screws.
For a more detailed description of xation of the greater
trochanter, see Chapter 7.

structure. Abduct the hip, return the gluteus medius and vastus
lateralis to their original position, and suture them to the
undisturbed part of the vastus lateralis, to the deep insertion of
the gluteus maximus, and to the proximal part of the quadratus
femoris.

Hardinge described a useful modication of the McFarland


and Osborne direct lateral approach based on the observation that the gluteus medius inserts on the greater trochanter by a strong, mobile tendon that curves around the apex
of the trochanter. This approach can be easily made with
the patient supine. Osteotomy of the greater trochanter is
avoided.
TECHNIQUE 1-54

McFarland and Osborne described a lateral approach to


the hip that preserves the integrity of the gluteus medius
muscle. They noted that the gluteus medius and vastus
lateralis muscles can be regarded as being in direct functional continuity through the thick periosteum covering
the greater trochanter.

Hardinge

Place the patient supine with the greater trochanter at the


edge of the table and the muscles of the buttocks freed from
the edge.
Make a posteriorly directed lazy-J incision centered over the
greater trochanter (Fig. 1-69A).

67

Chapter 1 Surgical Techniques and Approaches

Fig. 1-68 McFarland and Osborne lateral or posterolateral approach to hip.


A, Skin incision. B, Gluteal fascia and iliotibial band are divided in midlateral line. C, Incision is made to bone obliquely across trochanter and
distally in vastus lateralis. D, Combined muscle mass consisting of gluteus
medius and vastus lateralis with their tendinous junction is elevated and
retracted anteriorly. E, Tendon of gluteus minimus is split and divided
before retraction proximally. F, Capsule has been opened to expose joint.
(From McFarland B, Osborne G: Approach to the hip: a suggested improvement
on Kochers method, J Bone Joint Surg 36B:364, 1954.)

A
Tensor
fasciae
latae

Tensor
fasciae
latae

Tensor fasciae latae

Gluteus medius
Gluteus maximus

Gluteus medius
Gluteus maximus
(retracted)

Gluteus
minimus
Greater
trochanter

Gluteus
maximus

Vastus
lateralis

Vastus
lateralis

Gluteus medius

Gluteus medius

Gluteus minimus
(retracted)

Gluteus minimus
Gluteus maximus

Gluteus maximus

Greater
trochanter

Vastus
lateralis

Vastus
lateralis

68

Part I General Principles

Tensor fasciae
latae

A
Gluteus maximus
muscle

Vastus lateralis muscle

Gluteus medius muscle

C
Fig. 1-69 Hardinge direct lateral approach. A, Lazy-J lateral skin incision. B, Tensor fasciae
latae is retracted anteriorly, and gluteus maximus is retracted posteriorly. Incision through
gluteus medius tendon is outlined. Posterior half is left attached to greater trochanter. C,
Anterior joint capsule is exposed. (Modied from Hardinge K: The direct lateral approach to the
hip, J Bone Joint Surg 64B:17, 1982.)

TECHNIQUE 1-54 Hardingecontd


Divide the fascia lata in line with the skin incision and centered
over the greater trochanter.

Retract the tensor fasciae latae anteriorly and the gluteus


maximus posteriorly, exposing the origin of the vastus lateralis
and the insertion of the gluteus medius (Fig. 1-69B).
Incise the tendon of the gluteus medius obliquely across the
greater trochanter, leaving the posterior half still attached to the
trochanter. Carry the incision proximally in line with the bers of
the gluteus medius at the junction of the middle and posterior
thirds of the muscle. Distally, carry the incision anteriorly in line
with the bers of the vastus lateralis down to bone along the
anterolateral surface of the femur (see Fig. 1-69B).
Elevate the tendinous insertions of the anterior portions of
the gluteus minimus and vastus lateralis muscles. Abduction of
the thigh exposes the anterior capsule of the hip joint (Fig.
1-69C).

Incise the capsule as desired.


During closure, repair the tendon of the gluteus medius with
nonabsorbable braided sutures.

Frndak et al. modied the Hardinge direct lateral


approach by placing the abductor split more anterior,

directly over the femoral head and neck (Fig. 1-70). The
split must not extend more than 2 cm above the lateral
lip of the acetabulum to avoid damage to the gluteal neurovascular bundle. Because the abductor split is more
anterior, exposure of the femoral head and neck requires
less retraction.
McLauchlan described a direct lateral approach to the
hip through the gluteus medius used for many years by
Hay at the Stracathro Hospital. It also is based on the anatomical observation made by McFarland and Osborne
mentioned earlier that the gluteus medius and vastus lateralis are in functional continuity through the thick periosteum covering the greater trochanter.
TECHNIQUE 1-55

Hay as described by McLauchlan

Place the patient in the Sims position with the affected hip
uppermost.
Make a lateral longitudinal skin incision (Fig. 1-71A) centered
midway between the anterior and posterior borders of the
greater trochanter and extending an equal distance proximal and
distal to the tip of the trochanter. In lateral rotational deformities
of the hip, place the incision more posteriorly.
Incise the deep fascia and the tensor fasciae latae in line with
the skin incision.

Chapter 1 Surgical Techniques and Approaches

69

Gluteus medius
muscle

Vastus lateralis
muscle

Fig. 1-70 Modied direct lateral approach. A, Abductor split is determined by location of
the femoral neck. B, Capsular incision parallels superior border.

Retract these structures anteriorly and posteriorly to


expose the greater trochanter with the gluteus medius attached
to it proximally and the vastus lateralis attached distally (Fig.
1-71B).

Split the gluteus medius in the line of its bers, and with an
osteotome elevate two rectangular slices of greater trochanter,
one anteriorly and one posteriorly. These slices of trochanter
have gluteus medius attached to them proximally and vastus
lateralis attached distally (Fig. 1-71C).
Retract anteriorly and posteriorly to reveal the gluteus
minimus.

Posterolateral Approach
Gibson is responsible for the rediscovery in North America
of the posterolateral approach to the hip rst described and
recommended by Kocher and Langenbeck. Because detaching the gluteal muscles from the ilium and interfering with
the function of the iliotibial band are unnecessary, rehabilitation after surgery is rapid. Figure 1-72 shows a modication of the Gibson approach by Marcy and Fletcher in
which the hip is dislocated by internal rotation and the
anterior part of the joint capsule is preserved to keep the
hip from dislocating after surgery.

Rotate the hip externally, and split the gluteus minimus in the
line of its bers or detach it from the greater trochanter.

TECHNIQUE 1-56 Gibson

Incise the capsule of the hip joint, insert spike retractors

Place the patient in a lateral position.

anteriorly and posteriorly over the edges of the acetabulum,


and dislocate the hip anteriorly by exion and external
rotation (Fig. 1-71D). The femoral neck and acetabulum are
well exposed for routine total hip arthroplasty or for difcult
revisions.

Begin the proximal limb of the incision at a point 6 to 8 cm


anterior to the posterior superior iliac spine and just distal to the
iliac crest, overlying the anterior border of the gluteus maximus
muscle. Extend it distally to the anterior edge of the greater
trochanter and farther distally along the line of the femur for 15
to 18 cm (Fig. 1-73A).

When closing, suture the capsule if enough of it is left.


Internally rotate the hip and suture the trochanteric slices to
the periosteum and the other soft tissue covering the trochanter.
The trochanteric slices unite without any problem, and abductor
function returns rapidly.

Carefully close the deep fascia with interrupted sutures.

By blunt dissection, reect the aps of skin and subcutaneous


fat from the underlying deep fascia a short distance anteriorly
and posteriorly.
Incise the iliotibial band in line with its bers, beginning at
the distal end of the wound and extending proximally to the
greater trochanter.

70

Part I General Principles

A
Gluteus minimus
muscle

Gluteus medius
muscle

Gluteus minimus
muscle

Gluteus medius
muscle

Bone
slices

Vastus lateralis
muscle

Vastus lateralis
muscle

Fig. 1-71 Hay lateral approach to hip. A, Skin incision. B, Greater trochanter is exposed with
gluteus medius attached to it proximally and vastus lateralis distally. Solid line indicates incision
to be made in soft tissues. C, Rectangular slices of greater trochanter have been elevated
anteriorly and posteriorly. D, Hip joint has been opened and can be dislocated as described.
(Modied from McLauchlan J: The Stracathro approach to the hip, J Bone Joint Surg 66B:30, 1984.)

TECHNIQUE 1-56 Gibsoncontd


Abduct the thigh, insert the gloved nger through the
proximal end of the incision in the band, locate by palpation the
sulcus at the anterior border of the gluteus maximus muscle, and
extend the incision proximally along this sulcus. Adduct the
thigh, reect the anterior and posterior masses, and expose
the greater trochanter and the muscles that insert into it
(Fig. 1-73B).
Separate the posterior border of the gluteus medius muscle
from the adjacent piriformis tendon by blunt dissection.

Divide the gluteus medius and minimus muscles at their


insertions, but leave enough of their tendons attached to the
greater trochanter to permit easy closure of the wound. Reect
these muscles (innervated by the superior gluteal nerve)
anteriorly (Fig. 1-73C). The anterior and superior parts of the
joint capsule now can be seen.
Incise the capsule superiorly in the axis of the femoral neck
from the acetabulum to the intertrochanteric line; incise as much
of the capsule as desired along the joint line anteriorly and along
the anterior intertrochanteric line laterally. The hip now can be

Chapter 1 Surgical Techniques and Approaches

Gluteus
medius
muscle

71

Capsule opened
Greater
trochanter

Gluteus
maximus
muscle

Sciatic nerve

Excision of
external rotators

Fig. 1-72 Modication of Gibson posterolateral approach to hip. Anterior part of joint capsule
is preserved to keep hip from dislocating after surgery. Acetabulum is not well exposed, but
approach is sufcient for removing femoral head and inserting prosthesis.

dislocated by exing the hip and knee and abducting and


externally rotating the thigh (Fig. 1-73).

Sufcient exposure of the hip often can be obtained with less


extensive division of the muscles inserting on the trochanter; the
extent of division depends on the type of operation proposed,
the amount of exposure required, the tightness of the soft
tissues, and the presence or absence of contractures around the
joint. Conversely, when wide exposure of the joint, especially of

the acetabulum, is needed, more extensive division of the muscles


may be necessary. Gibson thinks that reattaching the muscles to
the greater trochanter by interrupted sutures is adequate.

To preserve the insertion of the abductor muscles, osteotomize


the trochanter and later reattach it with two wire loops or 6.5mm lag screws. Wire loops are passed through the insertion of
the muscles proximal to the trochanter and through a hole drilled
in the femoral shaft 4 cm distal to the osteotomy.

Gluteus
medius
muscle

Gluteus
maximus
muscle
Piriformis
muscle

Greater
trochanter

Short external
rotator muscles

Fascia

Vastus lateralis
muscle

Quadratus femoris
muscle

Gluteus maximus
muscle
Capsule

Gluteus medius and


minimus insertions

Vastus lateralis
muscle

Fig. 1-73 Gibson posterolateral approach


to hip joint. A, Skin incision. B, Anterior
and posterior muscle masses have been
retracted to expose greater trochanter and
muscles that insert into it. C, Gluteus
medius and minimus have been divided
near their insertions into greater trochanter and retracted. Incision in capsule is
shown. D, Hip joint has been dislocated
by exing, abducting, and externally
rotating thigh.

Chapter 1 Surgical Techniques and Approaches

Posterior Approaches

Separate the bers of the gluteus maximus parallel with the


line of incision. Relatively little bleeding occurs, because the
branches of the superior gluteal artery are contained in the
proximal half of the muscle, and the branches of the inferior
gluteal are contained in the distal half.

TECHNIQUE 1-57 Osborne


Begin the incision 4.5 cm distal and lateral to the posterior
superior iliac spine, and continue it laterally and distally, remaining
parallel with the bers of the gluteus maximus muscle, to the
posterosuperior angle of the greater trochanter, and distally along
the posterior border of the trochanter for 5 cm (Fig. 1-74).

Divide the insertion of the gluteus maximus into the fascia lata
for 5 cm, corresponding to the longitudinal limb of the incision.

Piriformis
muscle

Line of incision
Sciatic
nerve

Gemellus
muscles

Obturator
externus
muscle

Obturator
internus
muscle

Quadratus
femoris
muscle

Gluteus
maximus
muscle

73

B
Piriformis muscle

Gemellus
muscles
Joint
capsule

Quadratus
femoris
muscle

C
Fig. 1-74 Osborne posterior approach to hip joint. A, Skin incision. B, Gluteus maximus has
been opened in line with its bers and retracted. C, Piriformis, gemelli, and obturator internus
have been divided at their insertions and reected medially to expose posterior aspect of joint
capsule.

74

Part I General Principles

TECHNIQUE 1-57 Osbornecontd


Rotate the thigh internally, detach the tendons of the
piriformis and gemelli muscles near their insertions into the
trochanter, and retract the muscles medially. The gemelli protect
the sciatic nerve.

The capsule of the joint is now in view and may be incised


longitudinally to expose the posterior surface of the femoral neck
and posterior border of the acetabulum. Further exposure may
be obtained by retracting the gluteus medius muscle proximally
and the quadratus femoris muscle distally.

TECHNIQUE 1-58

Moore

Moores approach has been facetiously labeled the southern


exposure. Place the patient on the unaffected side.
Start the incision approximately 10 cm distal to the posterior
superior iliac spine, and extend it distally and laterally parallel
with the bers of the gluteus maximus to the posterior margin of
the greater trochanter. Direct the incision distally 10 to 13 cm
parallel with the femoral shaft (Fig. 1-75A).

Expose and divide the deep fascia in line with the skin incision.
By blunt dissection, separate the bers of the gluteus
maximus; take care not to disturb the superior gluteal vessels in
the proximal part of the exposure (Fig. 1-75B).

Retract the proximal bers of the gluteus maximus proximally,


and expose the greater trochanter. Retract the distal bers
distally, and partially divide their insertion into the linea aspera in
line with the distal part of the incision.

Expose the sciatic nerve and retract it carefully. (After the


surgeon becomes familiar with this approach, he or she rarely
exposes the sciatic nerve.) Divide a small branch of the sacral
plexus to the quadratus femoris and inferior gemellus, which
contains sensory bers to the joint capsule.
Expose and divide the gemelli and obturator internus and, if
desired, the tendon of the piriformis at their insertion on the
femur, and retract the muscles medially.

The posterior part of the joint capsule is now well exposed


(Fig. 1-75C); incise it from distal to proximal along the line of the
femoral neck to the rim of the acetabulum.
Detach the distal part of the capsule from the femur.
Flex the thigh and knee 90 degrees, internally rotate the thigh,
and dislocate the hip posteriorly (Fig. 1-75D).

Medial Approach
The medial approach to the hip, rst described by Ludloff
in 1908, was developed to permit surgery on a congenitally
dislocated hip with the hip exed, abducted, and externally
rotated. With the hip in this position, the distance from
the skin to the medial aspect of the femoral head and lesser

D
Fig. 1-75 Moore posterior approach to hip joint. A, Skin
incision. B, Gluteus maximus has been split in line with its
bers and retracted to expose sciatic nerve, greater trochanter, and short external rotator muscles. C, Short external
rotator muscles have been freed from femur and retracted
medially to expose joint capsule. D, Joint capsule has been
opened, and hip joint has been dislocated by exing, adducting, and internally rotating thigh.

trochanter is about half that present when the hip is in the


neutral position.
The muscular interval for the Ludloff approach is
believed to be between the sartorius and the adductor
longus with the deeper interval being between the iliopsoas
and pectineus, although Ludloff did not precisely dene
the interval in his original German articles. A review by
Mallon and Fitch claries the anatomical intervals for the
various medial approaches.
Ferguson and Hoppenfeld and deBoer described a medial
approach based on Ludloff s approach with the supercial
muscular interval between the gracilis and adductor longus
and the deep interval between the adductor brevis and
adductor magnus (Fig. 1-76).
TECHNIQUE 1-59 Ferguson; Hoppenfeld and deBoer
Make a longitudinal incision on the medial aspect of the thigh,
beginning about 2.5 cm distal to the pubic tubercle and over the
interval between the gracilis and the adductor longus muscles.

Chapter 1 Surgical Techniques and Approaches

Develop the plane between the adductor longus and brevis


muscles anteriorly and the gracilis and adductor magnus muscles
posteriorly.

Expose and protect the posterior branch of the obturator


nerve and the neurovascular bundle of the gracilis muscle. The
lesser trochanter and the capsule of the hip joint are located in
the oor of the wound.

75

Complications associated with these more extensile


approaches have led to the development of indirect reduction and percutaneous xation techniques for acetabular
fractures using only portions of these approaches if possible.
Many of these approaches can be adapted for difcult
primary or revision total hip arthroplasty.
Anterior Approaches
Ilioinguinal Approach

Acetabulum and Pelvis


Repair of acetabular and pelvic fractures has become
common in many centers. Computed tomography and
three-dimensional computerized scanning have aided
greatly in characterizing fracture congurations and in preoperative planning. Modications of more traditional
approaches have been developed for anterior, posterior, and
lateral acetabular fractures. Newer, truly extensile
approaches have been developed for more complex fractures involving the anterior and posterior columns of the
acetabulum and pelvis. Open reduction and internal xation of acetabular fractures is detailed in Chapter 53.

Letournel developed the ilioinguinal approach in 1960 as


an anterior approach to the acetabulum and pelvis for the
operative treatment of anterior wall acetabular and anterior
column pelvic fractures. The articular surface of the acetabulum is not exposed, which is a disadvantage. This
approach provides exposure of the inner table of the
innominate bone from the symphysis pubis to the anterior
aspect of the sacroiliac joint, however, including the quadrilateral surface and the superior and inferior pubic rami.
The hip abductor musculature is left undisturbed, and rapid
postoperative rehabilitation is possible.
A thorough knowledge of the surgical anatomy of this
area is necessary to avoid disastrous complications. Matta

Skin incision
Fascia
Gracilis
muscle

Adductor longus
muscle
Gracilis muscle

Adductor
longus
muscle

A
Adductor magnus muscle

Adductor brevis muscle

Adductor longus
muscle

Adductor longus
muscle

Cleavage
plane

Adductor brevis
muscle
Neurovascular
bundle of
gracilis muscle

Adductor magnus
muscle

Gracilis muscle

Gracilis muscle

Iliopsoas muscle
Adductor magnus muscle

Fig. 1-76 Ferguson; Hoppenfeld and deBoer medial approach to hip joint. A, Skin incision.
B, Plane between adductor longus and gracilis is to be developed. C, Adductor longus has
been retracted anteriorly, and gracilis and adductor magnus have been retracted posteriorly.
D, Lesser trochanter has been exposed.

76

Part I General Principles

External oblique
aponeurosis

Internal
oblique
muscle
Lateral
femoral
cutaneous
nerve

Ilioinguinal
nerve

Lateral
femoral
cutaneous
nerve

Inguinal
ligament

Iliopsoas
muscle

Reflected
aponeurosis

Femoral
nerve

Spermatic cord or
round ligament

External iliac vessels

D
Fig. 1-77 Letournel and Judet ilioinguinal approach. A, Skin incision. B, Origins of abdominal
and iliacus muscles have been elevated from iliac crest. Broken line shows incision through
supercial fascia and external oblique aponeurosis. C, Lateral femoral cutaneous nerve has been
exposed, and aponeurosis of external oblique has been incised. Iliacus has been reected from
inner table of ilium. Inguinal canal has been opened by reecting incised ap of external
oblique aponeurosis distally. Internal oblique, inguinal ligament, and spermatic cord or round
ligament have been exposed. D, Inguinal ligament has been incised releasing common origin
of internal oblique and transversus abdominis muscles.

advises the surgeon to practice on a cadaver and gain experience by assisting a surgeon familiar with this exposure
before undertaking the approach for the rst time.

TECHNIQUE 1-60

Letournel and Judet, as described by

Matta

Position the patient supine on a fracture table with skeletal


traction applied on the injured side through a distal femoral pin.
Traction should not be used in the presence of contralateral
superior and inferior pubic rami fractures, because deformity of
the anterior pelvic ring results from pressure from the perineal
post. Apply lateral traction, if necessary, through a traction screw
inserted into the greater trochanter and attached to a lateral
support on the fracture table.

Begin an incision 3 cm above the symphysis pubis and carry it


laterally across the lower abdomen to the anterior superior iliac
spine. Continue it posteriorly along the iliac crest to the junction
of the middle and posterior thirds of the crest (Fig. 1-77A).

Sharply elevate the origins of the abdominal muscles and the


iliacus muscle from the iliac crest.
Elevate the iliacus by subperiosteal dissection from the inner
table of the ilium as far as the anterior aspect of the sacroiliac
joint. Continue the incision anteriorly through the supercial
fascia to the external oblique aponeurosis and the external fascia
of the rectus abdominis muscle (Fig. 1-77B).
Sharply incise the aponeurosis of the external oblique and the
external fascia of the rectus abdominis at least 1 cm proximal to
the external inguinal ring and in line with the skin incision.

Chapter 1 Surgical Techniques and Approaches

Iliopsoas muscle

Iliopectineal fascia

Femoral nerve

Iliopectineal fascia

77

External iliac
vessels

Iliopectineal fascia
Femoral nerve

E, Iliopectineal fascia separates lacuna musculorum and lacuna vasorum. F,


Iliopectineal fascia is incised toward pectineal eminence. G, Internal iliac vessels have been
separated and retracted medially from iliopectineal fascia. H, Three regions of pelvis exposed
during approach.
Continued
Fig. 1-77, contd

Open the inguinal canal by elevating and reecting the distal


edge of the external oblique aponeurosis and the adjacent fascia
of the rectus abdominis (Fig. 1-77C). Protect the lateral femoral
cutaneous nerve, which may be adjacent to the anterior superior
iliac spine or 3 cm medial to it.
Identify the spermatic cord or round ligament and adjacent
ilioinguinal nerve. Bluntly free these structures and secure them
with a Penrose drain.

Clean the areolar tissue from the inguinal ligament, and incise
the ligament along its length carefully with a scalpel, leaving
1 mm of ligament attached to the internal oblique and
transversus abdominis muscles and the transversalis fascia (Fig. 177D). Exercise extreme caution to avoid damaging the structures
beneath the inguinal ligament.

Having released the common origin of the internal oblique and


transversus abdominis from the inguinal ligament, the psoas
sheath is entered. Continue to protect the lateral femoral
cutaneous nerve beneath the inguinal ligament.
To gain further exposure medially, retract the spermatic
cord or round ligament laterally, exposing the transversalis fascia
and conjoined tendon, which form the oor of the inguinal
canal.

Divide the conjoined tendon of the internal oblique and


transversus abdominis and the tendon of the rectus
abdominis at their insertions on the pubis to open the
retropubic space.

The structures beneath the inguinal ligament lie within two


compartments or lacunae. The lacuna musculorum is lateral and
contains the iliopsoas muscle, the femoral nerve, and the lateral
femoral cutaneous nerve. The lacuna vasorum is medial and
contains the external iliac vessels and lymphatics. The
iliopectineal fascia, or psoas sheath, separates the two
compartments (Fig. 1-77E). Carefully elevate the external iliac
vessels and lymphatics from the iliopectineal fascia by blunt
dissection and gently retract them medially.
Elevate the iliopectineal fascia from the underlying iliopsoas
and divide it sharply with scissors down to the pectineal
eminence (Fig. 1-77F and G), and continue the dissection laterally
beneath the iliopsoas until the muscle and surrounding fascia are
freed from the underlying pelvic brim. Pass a Penrose drain
beneath the iliopsoas, femoral nerve, and lateral femoral
cutaneous nerve for use as a retractor.
Using blunt nger dissection, begin mobilizing the external
iliac vessels and lymphatics, working from lateral to medial.
Search for the obturator artery and nerve medial and posterior to

78

Part I General Principles

Fig. 1-77, contd I, Lateral femoral cutaneous nerve,


iliopsoas, and femoral nerve have been retracted
medially to expose internal iliac fossa. J, Pelvic brim
and pectineal eminence have been exposed by lateral
retraction of iliopsoas and femoral nerve and medial
retraction of external iliac vessels. K, Medial aspect
of superior pubic ramus and pubic symphysis have
been exposed by release of rectus abdominis and
lateral retraction of external iliac vessels and
spermatic cord or round ligament.

TECHNIQUE 1-60

Letournel and Judet, as described by

Mattacontd
the vessels. Occasionally, the obturator artery has an anomalous
origin from the inferior epigastric artery instead of from the
internal iliac artery. If the anomalous obturator artery is present,
clamp, ligate, and divide it to avoid an avulsive traction injury.
Place a third Penrose drain around the external iliac vessels and
lymphatics. Leave the areolar tissue surrounding the vessels and
lymphatics intact.

To expose the internal iliac fossa and adjacent pelvic brim,


retract the iliopsoas and femoral nerve medially. Continue
elevation of the iliacus muscle subperiosteally to the
quadrilateral surface of the pelvis as necessary. Avoid injuring the
internal iliac and gluteal vessels as the dissection is continued
proximally along the quadrilateral space (Fig. 1-77H and I).
To increase the exposure of the superior pubic ramus, retract
the iliac vessels laterally and release the origin of the
pectineus muscle.
To obtain access to the entire pelvic brim distally to the lateral
aspect of the superior pubic ramus, the anterior wall of the

Rectus abdominis
muscle

acetabulum, the quadrilateral surface, and the superior aspect of


the obturator foramen, retract the iliopsoas and femoral nerve
laterally and the external iliac vessels medially (Fig. 1-77J). To gain
access to the superior aspect of the obturator foramen and the
superior pubic ramus, retract the external iliac vessels laterally and
the spermatic cord or round ligament medially. During retraction
of the external iliac vessels in either direction, check the pulse of
the internal iliac artery frequently, and lessen the traction force if
the pulse is interrupted. To obtain access to the medial aspect of
the superior pubic ramus and symphysis pubis, retract the
spermatic cord or round ligament laterally (Fig. 1-77K).

If necessary, release the inguinal ligament and sartorius muscle


from the anterior superior iliac spine, and elevate the tensor
fasciae latae and gluteal muscles from the external surface of the
iliac wing.
In repairing a pelvic fracture, preserve all substantial muscular
attachments to the fracture fragments to avoid devitalizing the
bone.

Before wound closure, insert suction drains into the retropubic


space and internal iliac fossa overlying the quadrilateral space.

Chapter 1 Surgical Techniques and Approaches

Reattach the abdominal fascia to the fascia lata on the iliac


crest with heavy sutures.

Reattach the tendon of the rectus abdominis to the


periosteum of the pubis.
Reattach the transversalis fascia and the internal oblique and
transversus abdominis muscles to the inguinal ligament.
Repair the iliopectineal fascia that separates the iliopsoas from
the fascia of the rectus abdominis and the aponeurosis of the
external oblique.

Bilateral Ilioinguinal Approach


The Letournel and Judet anterior ilioinguinal approach can
be used in a bilateral fashion for extensile exposure of the
entire anterior half of the pelvic ring, symphysis pubis, iliac
fossae, and the anterior aspects of both sacroiliac joints. The
skin incision described in Figure 1-77 is carried across the
opposite superior pubic ramus to the anterior superior iliac
spine and then posteriorly along the iliac crest (Fig. 1-78).
The insertions of both rectus abdominis muscles are

79

released. The remainder of the exposure is developed as


described in the unilateral ilioinguinal approach.
Letournel modied and improved the Smith-Petersen,
or iliofemoral, approach. The muscles on the inner wall of
the ilium are elevated to gain access to the anterior column
directly within the pelvis.

Iliofemoral Approach
TECHNIQUE 1-61

Letournel and Judet

Begin the skin incision at the middle of the iliac crest. Carry it
anteriorly over the anterior superior iliac spine and distally along
the medial border of the sartorius to the middle third of the
anterior thigh (Fig. 1-79A).
Divide the supercial and deep fascia.
Develop the interval between the tensor fasciae latae laterally
and the sartorius medially, exposing the rectus femoris.
Divide the sartorius at its attachment to the anterior superior
iliac spine.
Divide the external branch of the lateral femoral cutaneous
nerve.
Incise the anterior abdominal musculature from the iliac crest
and reect it medially.
Expose the iliac fossa by elevating the iliacus muscle (Fig. 179B). Carefully protect the femoral nerve and vessels and the
remaining branches of the lateral femoral cutaneous nerve that
lie just medial to the plane of the dissection.
Detach both origins of the rectus femoris, and reect the

muscle medially to expose the anterior surface of the hip joint


capsule and anterior wall of the acetabulum. The iliopsoas
tendon can be divided to provide more access to the anterior
column. Preserve the musculature on the external surface of the
iliac wing in this approach. Further reection of the iliacus and
abdominal musculature posteriorly and medially allows exposure
of the inner wall of the ilium to the sacroiliac joint. Anteriorly,
the superior pubic ramus can be exposed, but the symphysis
pubis cannot.

Posterior Approach
The combination of the Kocher approach and the
Langenbeck approach, described as the Kocher-Langenbeck
posterior approach by Letournel and Judet, provides access
to the posterior wall and posterior column of the
acetabulum.
TECHNIQUE 1-62

B
Fig. 1-78 Bilateral ilioinguinal approach. A, Skin incision
and deep dissection have been performed as described for
unilateral ilioinguinal approach (see Fig. 1-77). B, Insertions
of both rectus abdominis muscles have been released, and
symphysis and superior pubic rami have been exposed.

Kocher-Langenbeck; Letournel and

Judet

Place the patient in the lateral position with the affected hip
uppermost. If a fracture table and a supracondylar femoral
traction pin are used, keep the knee joint in at least 45 degrees
of exion to prevent excessive traction on the sciatic nerve.

80

Part I General Principles

Iliacus
muscle

Fig. 1-79 Letournel and Judet iliofemoral


approach. A, Skin incision. B, Anterior aspect
of hip joint and anterior column are exposed
by releasing sartorius and rectus femoris and
reecting iliacus medially.

A
Rectus
femoris
muscle

B
Gluteus medius
muscle

Sciatic nerve

Superior
gluteal
nerve
Sciatic
nerve

Quadratus
femoris
muscle

Piriformis
muscle

Fig. 1-80 Kocher-Langenbeck posterior approach. A, Skin incision. B, Incision of fascia lata
and splitting of gluteus maximus outlined. C, Gluteus maximus has been retracted exposing
short external rotators, sciatic nerve, and superior gluteal vessels. Ascending branch of medial
circumex femoral artery underlies quadratus femoris. D, Hip joint capsule has been exposed
by division and posterior reection of short external rotators. Quadratus femoris is left intact.
E, Osteotomy of greater trochanter and reection of hamstring origins from ischial tuberosity
have enlarged exposure.

Chapter 1 Surgical Techniques and Approaches

TECHNIQUE 1-62

Kocher-Langenbeck; Letournel and

Judetcontd

Begin the skin incision over the greater trochanter and extend
it proximally to within 6 cm of the posterior superior iliac spine
(Fig. 1-80A). The incision can be extended distally over the lateral
surface of the thigh for approximately 10 cm as necessary.

Divide the fascia lata in line with the skin incision, and bluntly
split the gluteus maximus in line with its muscle bers (Fig.
1-80B). Protect the branch of the inferior gluteal nerve to the
anterosuperior portion of the gluteus maximus to avoid
denervating that part of the muscle.
Identify and protect the sciatic nerve overlying the quadratus
femoris (Fig. 1-80C). Incise the short external rotators at their
tendinous insertions on the greater trochanter, and reect them
medially to protect the sciatic nerve further (Fig. 1-80D). Leave
the quadratus femoris intact to protect the underlying ascending
branch of the medial circumex femoral artery. The tendinous
insertion of the gluteus maximus on the femur can be incised to
increase exposure.

Elevate the gluteus medius and minimus subperiosteally from


the posterior and lateral ilium. Retraction of these muscles can
be maintained by inserting two smooth Steinmann pins into the
ilium above the greater sciatic notch. Identify and protect the
superior gluteal nerve and vessels as they exit the greater sciatic
notch. The entire posterior acetabulum and posterior column are
now exposed. Further exposure can be gained by an osteotomy
of the greater trochanter and reection of the origins of the
hamstrings from the ischial tuberosity (Fig. 1-80E).

Reattach the greater trochanter with two 6.5-mm lag screws


during wound closure.

Extensile Acetabular Approaches


Because complete exposure of anterior and posterior
columns of the acetabulum requires separate anterior and
posterior approaches, several surgeons developed extensile
approaches to the acetabulum to avoid the problems
encountered when using these separate approaches. Included
here are the approaches that we have found most useful.
For a more complete review of extensile acetabular
approaches, refer to the textbook of Mears and Rubash (see
reference list).
Extended Iliofemoral Approach
Letournel developed an extended iliofemoral approach that
provides complete exposure of the inner and outer table of
the ilium, acetabulum, and anterior and posterior columns.
It requires incision, however, of the origins and insertions
of the gluteus minimus and medius from the iliac crest and
the greater trochanter. Great care should be taken to avoid
damaging the superior gluteal vessels to prevent ischemic
necrosis of the hip abductors. In the presence of a fracture
through the greater sciatic notch and evidence by arteriogram of damage to the superior gluteal vessels, this approach
should not be used.

TECHNIQUE 1-63

81

Letournel and Judet

Place the patient in the lateral position on a fracture table if


distal femoral traction is necessary. If traction is not necessary, a
standard operating table can be used. Keep the knee joint exed
more than 45 degrees to avoid excessive traction on the sciatic
nerve.
Begin the incision at the posterior superior iliac spine and
extend it along the iliac crest, over the anterior superior iliac
spine, and carry it distally halfway down the anterolateral aspect
of the thigh (Fig. 1-81A).
Elevate the gluteal muscles and the tensor fasciae latae from
the outer table of the iliac wing as far anteriorly as the anterior
superior iliac spine. Division of some of the posterior branches of
the lateral femoral cutaneous nerve is inevitable, but protect the
main trunk of the nerve.
Open the fascia covering the greater trochanter and vastus
lateralis longitudinally.

Isolate, ligate, and divide the lateral femoral circumex artery


(Fig. 1-81B).

Continue the dissection posteriorly to the greater sciatic notch.


Carefully identify and protect the superior gluteal vessels and
nerve.

Divide the tendons of the gluteus minimus and medius, dissect


these muscles from the hip joint capsule, and reect them
posteriorly (Fig. 1-81C).
Divide the tendons of the piriformis and obturator internus at
their insertions on the greater trochanter, and elevate these
muscles from the hip joint capsule. The sciatic nerve exits the
greater sciatic foramen beneath the piriformis muscle and must
be protected. A retractor can be placed in the greater sciatic
notch; gentle retraction exposes the posterior column (Fig. 181D). Avoid a traction injury to the sciatic nerve in this exposure.
Leave the quadratus femoris muscle intact to protect the
ascending branch of the medial circumex femoral artery.
Open the hip joint by a capsulotomy around the rim of the
acetabulum.
Exposure of the internal surface of the ilium and anterior
column proceeds as in a routine iliofemoral approach.
Elevate the abdominal muscles and iliacus from the iliac crest
of the ilium, and divide the attachments of the sartorius and
inguinal ligament subperiosteally from the anterior superior iliac
spine. Divide the origins of the direct and reected heads of the
rectus femoris to expose the anterior portion of the hip joint
capsule (Fig. 1-81E).
During wound closure, reattach the rectus femoris, sartorius,
fascial layers of the hip abductor musculature, and tensor fasciae
latae to the iliac wing with sutures passed through the bone.
Repair the gluteus minimus and medius tendons anatomically.
Reattach the tendons of the piriformis and obturator internus
to the greater trochanter also with transosseous sutures.

82

Part I General Principles

Superior gluteal
vessels and nerve

Sartorius
muscle

Gluteal
muscles

Rectus femoris
muscle

A
Lateral circumflex
femoral vessels

Tensor
fascia
latae

Piriformis muscle

Sartorius
muscle
Sciatic
nerve
Obturator
internus
muscle

Rectus
femoris
muscle

Joint
capsule

Vastus
lateralis
muscle

Quadratus femoris
muscle

Fig. 1-81 Letournel and Judet extended iliofemoral approach. A, Skin incision. B, Gluteal
muscles and tensor fasciae latae have been partially elevated and retracted posteriorly. Lateral
femoral circumex vessels have been isolated. C, Tendon of gluteus minimus has been completely severed from anterior aspect of greater trochanter. Gluteus medius tendon has been
partially incised. D, Reection of piriformis, obturator internus, and gluteal muscles has exposed
external surface of innominate bone. E, Internal surface of ilium and anterior acetabulum and
hip joint have been exposed by reection of iliacus, sartorius, and rectus femoris (see text).

Reinert et al. developed a modication of the Letournel


and Judet extended iliofemoral approach designed to allow
later reconstructive procedures. It provides exposure for
repair of complex and both-column acetabular fractures.
The skin incision is positioned more laterally. Also, the hip
abductors are mobilized by osteotomies of their origins and
insertions. Rigid bone-to-bone reattachment of these
muscles permits early rehabilitation with less risk of failure

than when the abductors are reattached through soft tissue.


As with the extended iliofemoral approach, the patency of
the superior gluteal artery is necessary to avoid catastrophic
necrosis of the hip abductors. In the presence of a displaced
fracture at the sciatic notch, a preoperative arteriogram is
recommended. If a later reconstructive procedure is
required, the same operative site can be approached using
part or all of the same skin incision as necessary.

Chapter 1 Surgical Techniques and Approaches

Reinert et al. reported the use of this approach in 20


patients. One patient required resection of the tensor fasciae
latae during the primary operation because it had been
devitalized during the approach. Five patients developed
severe heterotopic ossication; however, the incidence of
this complication in patients requiring an extensile exposure for treatment of an acetabular fracture is not well
documented in other series. No patient developed skin ap
necrosis.
TECHNIQUE 1-64

Reinert et al.

Place the patient in the lateral position. Drape the lower


extremity free on the side of the pelvic injury.

Begin the skin incision 2 cm posterior to the anterior superior


iliac spine, and carry it posteriorly along the iliac crest for 8 to
12 cm. Make the vertical limb of the T incision by incising from
the midportion of the iliac crest incision in a curvilinear fashion
down the lateral aspect of the thigh to a point 15 cm distal to
the greater trochanter (Fig. 1-82A).

Develop the anterior ap by dissecting the subcutaneous tissue


from the deep fascia until the anterior superior iliac spine and
the interval between the sartorius and tensor fasciae latae
muscles are reached. Protect the lateral femoral cutaneous nerve.
Develop the posterior ap in the same fashion.

83

Flex the hip to 45 degrees and abduct it. Incise the fascia lata
longitudinally from the center of the greater trochanter distally to
a point 2 cm distal to the insertion of the tensor fasciae latae
muscle.
Incise the gluteal fascia and bluntly split the gluteus maximus
in line with its bers until the inferior gluteal nerve and vessels
are encountered.

Divide the anterior portion of the fascia lata transversely 2 cm


distal to the insertion of the tensor fasciae latae muscle. Release
the proximal portion of the gluteus maximus insertion on the
femur.

Bluntly develop the interval between the tensor fasciae latae


and the sartorius.
Continue the deep dissection anterior and posterior to the
tensor fasciae latae, separating it from the sartorius and the
rectus femoris.
Carefully identify, ligate, and divide the ascending branch of
the lateral femoral circumex artery in the proximal part of the
dissection. Microvascular reanastomosis of this artery can be
used as a substitute to restore collateral circulation to the hip
abductors should the superior gluteal artery be severely damaged
during the procedure.
Elevate the abdominal and iliacus muscles from the iliac crest
subperiosteally. Extend the dissection posteriorly to expose the
anterior aspect of the sacroiliac joint and sciatic notch as
necessary.
Perform an osteotomy of the anterior superior iliac spine, and
reect the attached sartorius and inguinal ligament medially,
along with the abdominal and iliacus muscles.
With an osteotome or 90-degree power cutting tool, perform
an osteotomy of the tricortical portion of the iliac crest
beginning along the inner table and producing a fragment 10 to
12 cm long and 1.5 cm high (Fig. 1-82B and C). Leave the hip
abductor muscles attached to the fragment, and reect this
musculo-osseous ap laterally.
Elevate the abductors subperiosteally from the outer table of
the ilium during this reection. Carefully preserve the superior
gluteal nerve and vessels.

Perform a standard trochanteric osteotomy, and release the


abductors from the hip joint capsule.
Carefully reect the abductors and attached greater trochanter
posteriorly (Fig. 1-82D and E). Release the short external rotators
from the greater trochanter. The quadratus femoris is preserved,
protecting the ascending branch of the medial circumex femoral
artery.
Identify and protect the sciatic nerve. Further avoid traction

A
Fig. 1-82 Modied iliofemoral approach. A, Skin incision.
Cutaneous aps have been developed. Broken line indicates
incision through fascia lata.
Continued

injury to the sciatic nerve by maintaining the hip extended and


the knee exed to at least 45 degrees.

If further anterior exposure is needed, release the direct and


reected heads of the rectus femoris (Fig. 1-82E). Incise the hip
joint capsule circumferentially at the acetabular labrum.

84

Part I General Principles

Anterior
column

Anterior
column
Posterior
column

Weight-bearing
dome

Posterior
column

Anterior superior
iliac spine

Superior gluteal
artery and nerve
Rectus
muscle
Incision
to release
rectus muscle

Fig. 1-82, contd B and C, Osteotomies of iliac crest, anterior superior iliac spine, and greater
trochanter. D, Osteotomies have been completed, and muscle aps have been reected exposing
anterior column. E, Posterior column has been exposed. Broken line depicts incision for release
of rectus muscle (see text). (From Reinert CM, Bosse MJ, Poka A, et al: A modied extensile
exposure for the treatment of complex or malunited acetabular fractures, J Bone Joint Surg 70A:329,
1988.)

Chapter 1 Surgical Techniques and Approaches

TECHNIQUE 1-64

Reinert et al.contd

During closure, reattach the origins of the rectus femoris with


heavy sutures through holes drilled in the anterior inferior iliac
spine.
Repair all osteotomies with lag-screw xation.
Repair the fascia lata, and reattach the iliacus and abdominal
muscles to the iliac crest with heavy sutures.

Mears and Rubash modied Charnleys initial total hip


arthroplasty approach and developed an extensile acetabular
approach providing access to the acetabulum, the anterior
and posterior columns, the inner iliac wall, the anterior
aspect of the sacroiliac joint, and the outer aspect of the
innominate bone. This triradiate approach was developed
for reduction and repair of complex acetabular fractures. It
avoids the potential complication of massive ischemic
necrosis of the hip abductors caused by injury to the superior gluteal vessels, which is a possibility when the extended
iliofemoral approach is used. Krackow et al. also used this
approach for difcult primary and revision total hip
arthroplasty.

Triradiate Extensile Approach


TECHNIQUE 1-65

Mears and Rubash

Place the patient in the lateral position on a conventional


operating table. A fracture table can be used if skeletal traction
is necessary. Keep the knee joint in at least 45 degrees of exion
to avoid excessive traction on the sciatic nerve.

85

Begin the longitudinal portion of the triradiate incision at the


tip of the greater trochanter, and carry it distally 6 to 8 cm. Carry
the anterosuperior limb from the tip of the greater trochanter
across the anterior superior iliac spine. Begin the posterosuperior
limb of the incision at the tip of the greater trochanter as well,
and carry it to the posterior superior iliac spine, forming an angle
of approximately 120 degrees (Fig. 1-83A).
Divide the fascia lata in line with its bers in the longitudinal
limb of the incision.
Incise the fascia lata and fascial covering of the tensor fasciae
latae in line with the anterosuperior limb of the incision (Fig.
1-83B).
Dissect the anterior border of the tensor fasciae latae from its
overlying fascia and elevate the origin of the muscle from the
iliac crest. Elevate subperiosteally from the iliac crest the origins
of the gluteus medius and minimus from anterior to posterior
and distally to the hip joint capsule.

Incise the fascia of the gluteus maximus in line with the


posterosuperior limb of the incision, and split the muscle in line
with its bers (Fig. 1-83C).

Perform an osteotomy of the greater trochanter, and reect


the trochanter with the attached insertions of the gluteus medius
and minimus proximally.
Sharply elevate the gluteus medius and minimus from the
capsule of the hip joint, preserving the capsule during the
dissection. Continue the dissection to the greater sciatic
notch and identify and protect the superior gluteal vessels (Fig.
1-83D).

Gluteus medius
muscle
Tensor fasciae
latae
Anterior superior
iliac spine

A
B
Vastus
lateralis
muscle

C
Fig. 1-83 Triradiate extensile approach. A, Skin incision. B, Supercial fascial incision.
C, Origin of tensor fasciae latae has been elevated from anterior iliac crest. Gluteus maximus
has been split in line with its bers up to inferior gluteal nerve and vessels.
Continued

86

Part I General Principles

Greater
trochanter
Sciatic
nerve

Rectus femoris
muscle
Joint capsule

Sacroiliac joint
Piriformis muscle

Sciatic
nerve
Rectus
femoris
muscle

Lateral
femoral
cutaneous
nerve

Joint capsule

Femoral nerve

F
Fig. 1-83, contd D, Greater trochanter has been osteotomized and reected posteriorly exposing
sciatic nerve and short external rotators. Gluteal and tensor fasciae latae muscles have been
elevated from outer table of ilium and hip joint capsule and reected posteriorly. E, Short
external rotators have been severed from greater trochanter and reected posteriorly. Quadratus
femoris remains intact. Gluteal and tensor fasciae latae muscles have been retracted superiorly
and held with Steinmann pins to expose posterior column. Joint capsule has been severed circumferentially from acetabulum. F, Abdominal muscles have been incised and iliacus muscle
elevated subperiosteally from ilium and reected medially to expose inner table of ilium (see
text and also Fig. 1-81E). (Modied from Mears DC, Rubash HE: Pelvic and acetabular fractures,
Thorofare, NJ, 1986, SLACK.)

Chapter 1 Surgical Techniques and Approaches

Triradiate Extensile Approach


TECHNIQUE 1-65

Mears and Rubashcontd

Divide the insertions of the short external rotators on the


proximal femur, including the upper third of the quadratus
femoris. Leave intact the remainder of this muscle and the
underlying ascending branch of the medial circumex femoral
artery.
Reect the divided short external rotators posteriorly to expose
the posterior aspect of the hip joint capsule and the posterior
column.
Maintain the exposure of the posterior column by carefully
inserting blunt Hohmann retractors into the greater and lesser
sciatic notches.

Secure the abductor muscles superiorly by inserting two


Steinmann pins into the ilium 2.5 cm and 5 cm above the greater
sciatic notch (Fig. 1-83E).
Sharply incise the origins of the hamstrings to expose the
ischial tuberosity.
To expose the anterior column and inner table of the ilium,
extend the anterosuperior limb of the skin incision 6 to 8 cm
medial to the anterior superior iliac crest.

Incise the abdominal musculature from the anterior iliac crest,


and elevate subperiosteally the iliacus muscle from the inner
table of the ilium. Continue the dissection posteriorly to expose
the anterior aspect of the sacroiliac joint (Fig. 1-83F).

To increase the exposure further, divide the origin of the


sartorius from the anterior superior iliac spine and the origins of
the direct and reected heads of the rectus femoris from the
anterior inferior iliac spine and hip joint capsule.
Incise the aponeurosis of the external oblique muscle 1 cm
proximal to the external inguinal ring and in line with the
inguinal ligament as described for the ilioinguinal approach.
Carefully develop the interval between the external iliac vessels
medially and the psoas muscle laterally. Next, develop the
interval between the external iliac vessels and the spermatic cord
or round ligament (see Fig. 1-77B to K).
Use the longitudinal intervals developed, and expose
subperiosteally the superior pubic ramus and quadrilateral surface
of the pelvis.

Incise the joint capsule of the hip circumferentially at the edge


of the acetabulum as far anteriorly and posteriorly as necessary,
but leave the acetabular labrum intact.
During closure, reattach the abdominal fascia to the fascia lata
along the iliac crest with heavy sutures.
Reattach the gluteal muscle origins and the tensor fasciae
latae to the iliac crest.
Drill small holes in the ilium and use heavy sutures to reattach
the origins of the rectus femoris and sartorius muscles.

87

Repair the trochanteric osteotomy with two long 6.5-mm


cancellous screws with washers.
Close the three fascial limbs of the triradiate incision,
beginning with a single apical suture.

Complete the closure of each limb of the incision.

Carnesale combined Henrys reection of the gluteus


maximus with several other approaches to the hip joint to
form an extensile approach for open reduction of complex
acetabular fractures. The posterior or anterior part of the
approach may be used alone as indicated in the given
instance; the entire approach is rarely required.

Extensile Approach to the Acetabulum


TECHNIQUE 1-66

Carnesale

Secure the patient on the uninjured side on a standard


operating table so that the table may be tilted to either side.
Prepare the skin from the middle of the rib cage to below the
knee.
Drape to allow free manipulation of the extremity.
Start the skin incision at the posterior superior iliac spine,
extend it anteriorly parallel to the iliac crest, and end it just
proximal to the anterior superior iliac spine (Fig. 1-84A). If the
anterior part of the approach is to be used, extend the incision
into the groin crease (see Fig. 1-84G). Perpendicular to this
transverse incision, incise the skin distally in the lateral midline of
the thigh, cross the center of the greater trochanter, and at the
gluteal fold turn the incision 90 degrees posteriorly and extend it
to the posterior midline of the thigh; if necessary, extend it
distally in the posterior midline of the thigh for 4 or 5 cm.
Raise appropriate aps of skin, investing fascia anteriorly and
posteriorly (Fig. 1-84B).
Reect the gluteus maximus, leaving it attached medially at its
pelvic origin as described by Henry as follows:
In the distal part of the incision, locate the posterior
cutaneous nerve of the thigh just beneath the deep fascia.
Open this fascia and trace the nerve to the distal edge of the
gluteus maximus; the nerve will be freed from the muscle
later.
Free the femoral side of the gluteus maximus by longitudinally
splitting the part of the iliotibial band that slides on the
femoral shaft and greater trochanter.
Extend the incision in the iliotibial band slightly proximally; at
this point, insert a nger, locate the superior border of the
gluteus maximus where it joins the iliotibial band, and with
the scissors, free this border of the muscle proximal to the
iliac crest (Fig. 1-84C and D).

88

Part I General Principles

Posterior
cutaneous
nerve of
thigh

Gluteus
maximus muscle

Gluteus maximus muscle


reflected

Sciatic
nerve

Reflected
external
rotators

E
Fig. 1-84

A-J, Carnesale extensile exposure of acetabulum (see text).

Extensile Approach to the Acetabulum


TECHNIQUE 1-66

Carnesalecontd

Raise the distal edge of the gluteus maximus and the


posterior cutaneous nerve of the thigh, and divide the thick
insertion of the muscle from the femur. Control the constant
vessel found at this insertion.
Detach the posterior cutaneous nerve of the thigh from
the deep surface of the gluteus maximus, and gently reect
the muscle medially, hinged on its pelvic attachment (Fig.
1-84E).

Detach the short external rotators from the greater trochanter,


reect them medially, and strip them subperiosteally from the
ilium sufciently to expose the posterior acetabular wall. If more
superior exposure of the acetabulum is required, osteotomize the

greater trochanter, and with it reect the hip abductors


proximally (Fig. 1-84F).

In fractures of the anterior aspect of the acetabulum, continue


the skin incision anteriorly to the groin crease as already
described (Fig. 1-84G).
Locate the lateral femoral cutaneous nerve and preserve it (Fig.
1-84H).
Detach the inguinal ligament, sartorius, and rectus femoris
from the pelvis, but leave the tensor fasciae latae intact (Fig.
1-84I).
Strip subperiosteally the iliacus and, if necessary, the obturator
internus from the medial pelvic wall, exposing the anterior aspect
of the acetabulum (Fig. 1-84J).

89

Chapter 1 Surgical Techniques and Approaches

Reflected
greater
trochanter

Inguinal
ligament

Tensor
fasciae
latae

Lateral femoral
cutaneous nerve
Pectineal
line

Sartorius
muscle
Sartorius
muscle
Rectus
femoris
muscle

Fig. 1-84, contd

Ilium
TECHNIQUE 1-67
Incise the skin along the iliac crest from the anterior superior
spine to the posterior superior spine.
Reect the attachments of the gluteal muscles subperiosteally,
proximally to distally, as far as the superior rim of the
acetabulum, and expose the lateral surface of the ilium.
Reect subperiosteally the attachment of the abdominal
muscles from the iliac crest, or osteotomize the crest, leaving the

abdominal muscles attached to the superior fragment. In


children, make the osteotomy of the crest inferior to the
epiphyseal plate. Reect subperiosteally the iliacus muscle from
the medial surface of the ilium. Also divide at their origins the
structures attached to the anterior superior spine and the
anterior border of the ilium. Most of the ilium can be denuded.

In this procedure, a nutrient artery on the lateral surface of the


ilium 5 cm inferior to the crest and near the juncture of the
anterior and middle thirds is divided. Because ligating it is
impossible, control the bleeding with the point of a small
hemostat or, if necessary, with bone wax.

90

Part I General Principles

Ischium
TECHNIQUE 1-68

Radley, Liebig, and Brown

This technique is discussed in Chapter 19.

Symphysis Pubis

With an osteotome, remove a full-thickness section of the


ilium 1.5 to 2 cm wide, beginning at its posterior border
between the posterior superior and posterior inferior spines and
proceeding laterally and slightly cephalad for 4 to 5 cm. The
inferior border of this section roughly parallels the superior
border of the greater sciatic notch.
Exposure of the joint is limited by the size of the section
removed.

TECHNIQUE 1-69 Pfannenstiel


Place the patient supine, and insert a Foley catheter for
intraoperative identication of the base of the bladder and the
urethra.
Make a curvilinear transverse incision 2 cm cephalad to the
superior pubic ramus (Fig. 1-85A).
Incise the external oblique aponeurosis parallel to the inguinal
ligament.
Identify the spermatic cords or round ligaments and adjacent
ilioinguinal nerves. Release the aponeurotic insertion of both
heads of the rectus abdominis from the superior pubic ramus
(Fig. 1-85B).

Expose subperiosteally the superior, anterior, and posterior


surfaces of both rami laterally for 4 to 5 cm as necessary (Fig. 185C). During this dissection, identify the urethra and base of the
bladder by manual palpation of the Foley catheter.

During wound closure, insert a suction drain into the


retropubic space and repair the rectus abdominis with heavy
interrupted sutures.

Carefully repair the external oblique aponeurosis to prevent an


inguinal hernia.

Sacroiliac Joint
Posterior Approach
B
TECHNIQUE 1-70
Make an incision along the lateral lip of the posterior third of
the iliac crest to the posterior superior spine.
Deepen the dissection down to the crest, separate the
lumbodorsal fascia from it, detach and reect medially the
aponeurosis of the sacrospinalis muscle together with the
periosteum, and expose the posterior margin of the sacroiliac
joint. This exposure is ample for extraarticular fusion.
To expose the articular surfaces of the joint for drainage or
intraarticular fusion, continue the skin incision laterally and
distally 5 to 8 cm from the posterior superior spine. Split the
gluteus maximus muscle in line with its bers, or incise its origin
on the iliac crest, the aponeurosis of the sacrospinalis, and the
sacrum, and reect it laterally and distally to expose the posterior
aspect of the ilium.

C
Fig. 1-85 Pfannenstiel transverse approach to pubic symphysis. A, Skin incision. B, Rectus abdominis insertions
have been released. C, Entire pubic symphysis has been
exposed.

Chapter 1 Surgical Techniques and Approaches

Anterior Approach
Sometimes primary suppurative arthritis of the sacroiliac
joint may localize anteriorly; Avila approaches this region
by an intrapelvic route. This approach also is useful for
open reduction and plating of sacroiliac joint dislocation.
TECHNIQUE 1-71

Avila

lateral attachments of the anterior sacroiliac ligament; detach


them and palpate the joint.

To expose the anterior aspect of the joint, extend the incision


further posteriorly in the intermuscular plane along the iliac crest.

Both Sacroiliac Joints or Sacrum

With the patient supine, make a 10- to 12-cm incision 1.5 cm


proximal to and parallel with the iliac crest, beginning at the
anterior superior iliac spine.

Dissect distally to the iliac crest, and detach the abdominal


muscles from it without disturbing the origin of the gluteal
muscles.
Incise the periosteum and strip the iliacus muscle
subperiosteally, following the medial surface of the ilium medially
and slightly distally.
Retract the iliacus medially and complete the stripping by hand
with the gloved nger covered with gauze. Proceed as far as the

When bilateral, unstable sacroiliac disruptions or comminuted vertical fractures of the sacrum occur as part of a
pelvic ring disruption, Mears and Rubash approach these
through a transverse incision made across the midportion
of the sacrum. These injuries can be stabilized with a contoured reconstruction plate through this approach.
TECHNIQUE 1-72

Modied from Mears and Rubash

With the patient prone, make a transverse straight incision


across the midportion of the sacrum 1 cm inferior to the
posterior superior iliac spines (Fig. 1-86A). If one or both of the

91

Fig. 1-86 Exposure of both sacroiliac joints or sacrum. A, Skin incision. B, Posterior iliac
crests, gluteus maximus muscles, and paraspinous muscles have been exposed. C, Outline of
osteotomies of posterior superior iliac spines for application of plate and screws. D, Osteotomies
have been performed, and gluteus maximus muscles have been reected laterally.

92

Part I General Principles

TECHNIQUE 1-72

Modied from Mears and

Sternoclavicular Joint

Rubashcontd

TECHNIQUE 1-73
sciatic nerves are to be explored, curve the ends of the incision
distally to allow exposure of the sciatic nerves from the sacrum
to the greater sciatic notch.

Extend the incision through the deep fascia to expose the


superior portions of the origins of both gluteus maximus muscles
on the posterior superior iliac spines (Fig. 1-86B).
Elevate the paraspinous muscles from the posterior superior
iliac spines, and perform an osteotomy of each spine posterior to
the sacrum, from medial to lateral, leaving the origins of the
gluteus maximus muscles intact (Fig. 1-86C and D). This provides
a at surface for application of a plate.
Elevate the paraspinous muscles subperiosteally from the
sacrum and adjacent posterosuperior iliac spines to provide a
tunnel for application of a plate.
Remove the tips of the spinous processes of the sacrum as
necessary.
If further exposure is necessary for drainage of a sacroiliac
joint or intraarticular fusion, split the gluteus maximus muscle
on that side or incise its origin from the posterior superior iliac
spine, and reect it laterally to expose the posterior aspect of
the ilium.

Perform a larger osteotomy of the posterior ilium as described


for the standard posterior approach to the sacroiliac joint (see
Technique 1-70).

Make an incision along the medial 4 cm of the clavicle and


over the sternoclavicular joint to the midline of the sternum.
Incise the fascia and periosteum; reect subperiosteally the
origins of the sternocleidomastoid and pectoralis major muscles,
the rst superiorly and the second inferiorly; and expose the
sternoclavicular joint. When the deep surface of the joint must
be exposed, avoid puncturing the pleura or damaging an
intrathoracic vessel.

Acromioclavicular Joint
TECHNIQUE 1-74

Make a curved incision along the anterosuperior margin of the


acromion and the lateral one fourth of the clavicle (Fig. 1-87).
Expose the origin of the deltoid, free it from the clavicle and
the anterior margin of the acromion, and expose the capsule of
the acromioclavicular joint. (By retracting the deltoid distally, the
coracoid process also may be exposed.)

Shoulder
Anteromedial Approaches
TECHNIQUE 1-75

Spine
Surgical approaches to the spine are discussed in Chapter
34.

Roberts

Thompson; Henry

Begin the incision over the anterior aspect of the


acromioclavicular joint, passing it medially along the anterior
margin of the lateral one third of the clavicle and distally along

Coracoclavicular
ligament
Acromioclavicular
joint
Fig. 1-87 Roberts exposure of acromioclavicular joint and coracoid
process of scapula. A, Skin incision.
B, Deltoid muscle detached from
clavicle and acromion, exposing
acromioclavicular joint and being
retracted distally for exposure of
coracoid process.

Clavicle

Coracoid
process

A
Reflected deltoid
muscle
Coracoacromial
ligament

Chapter 1 Surgical Techniques and Approaches

Acromion
process

Reflected deltoid
muscle

Line of skin incision


Deltoid
muscle

Clavicle
Coracoid
process
Insertion of
subscapularis
muscle

Pectoralis
major
muscle

Cephalic vein
Long head of
biceps muscle

93

Short head of
biceps muscle
Insertion of
pectoralis major
muscle

B
Fig. 1-88 Anteromedial approach to shoulder joint. A, Skin incision. Transverse part of incision
has been made along anterior border of clavicle and longitudinal part along interval between
deltoid and pectoralis major. B, Deltoid has been detached from clavicle and reected laterally
to expose anterior aspect of joint.

the anterior margin of the deltoid muscle to a point two thirds


the distance between its origin and insertion (Fig. 1-88).

into the lesser humeral tuberosity; separate the tendon medially


from the underlying capsule and expose the glenoid labrum.

Expose the anterior margin of the deltoid. The cephalic vein


and the deltoid branches of the thoracoacromial artery lie in
the interval between the deltoid and pectoralis major muscles
(the deltopectoral groove), and although the cephalic vein may
be retracted medially along with a few bers of the deltoid
muscle, it may be damaged during the operation. Ligating
this vein proximally and distally as soon as it is reached may
be indicated.

When closing the wound, some surgeons replace the tip of


the coracoid; if this is done with a screw, it is helpful to drill a
hole in the process before osteotomy. We prefer to excise the tip
subperiosteally and to suture the origins of the coracobrachialis,
the pectoralis minor, and the short head of the biceps to the
coracoid.

Dene the origin of the deltoid muscle on the clavicle; detach


it by dividing it near the bone or at the bone together with the
adjacent periosteum or by removing part of the bone intact with
it. We prefer the rst method, leaving enough soft tissue
attached to the clavicle to allow suturing the deltoid to its
origin later.

If an extensile exposure is unnecessary, the skin incisions and


deeper dissection may be limited to the deltopectoral portion of
the approach. The anterior deltoid muscle need not be detached
from the clavicle. Approach the joint anteriorly without an
osteotomy of the coracoid process by retracting the short head
of the biceps muscle in a medial direction. Take care to avoid a
traction injury to the musculocutaneous nerve lying beneath the
short head of the biceps in the distal part of this wound.

Laterally reect the anterior part of the deltoid muscle to


expose the structures around the coracoid process and the
anterior part of the joint capsule.
To expose the deep aspects of the shoulder joint more easily,
including the anterior margin of the glenoid, osteotomize the
tip of the coracoid process. First, incise the periosteum of the
superior aspect of the coracoid; next, cut through the bone and
reect medially and distally the tip of the bone along with the
attached origins of the coracobrachialis, the pectoralis minor, and
the short head of the biceps.

For wider exposure, divide the subscapularis at its


musculotendinous junction about 2.5 cm medial to its insertion

Suture the deltoid in place, and close the wound in the usual
way.

Instead of this curved anteromedial approach, Henry later used


an incision that arches like a shoulder strap over the shoulder
from anterior to posterior (Fig. 1-89). The anterior part of this
incision is similar to the deltopectoral part of his original
approach, but at its superior end it proceeds directly over the
superior aspect of the shoulder and distally toward the spine of
the scapula. Mobilize a lateral ap by dissecting between the
subcutaneous tissues and the deep fascia, and expose the lateral
and posterior margins of the acromion and adjacent spine of the
scapula. Detach as much of the deltoid as needed to reach the
deeper structures sought.

94

Part I General Principles

Detach the origin of the deltoid from the acromion and from
the exposed part of the spine of the scapula, and reect the
deltoid inferiorly and laterally to expose the anterior, superior,
and posterior parts of the joint capsule.

Fig. 1-89

Henry shoulder strap or suspender incision.

If a wider eld is needed, the anteromedial approach


may be modied as Cubbins, Callahan, and Scuderi
suggest.
TECHNIQUE 1-76

Cubbins, Callahan, and Scuderi

Make the anterior limb of the Cubbins incision similar to that


in the anteromedial approach. Extend the incision laterally
around the acromion and medially along the lateral half of the
spine of the scapula (Fig. 1-90A).

Reach the joint anteriorly or posteriorly by a corresponding


incision of the capsule (Fig. 1-90B). To expose the articular
surface of the humerus and the glenoid, incise the capsule
continuously from anterior to posterior over the head of the
humerus; take care not to sever the tendon of the long head of
the biceps (Fig. 1-90C). In this approach, the bers of the deltoid
are not divided, and the axillary nerve that supplies the deltoid is
not disturbed.

Any part of the approaches to the shoulder described so


far can be used for operations on more limited regions
around the shoulder. Roberts used the part that exposes
the acromioclavicular joint and coracoid process for repairing ligaments ruptured by separation of that joint.
Anterior Axillary Approach
The anterior axillary approach, used often in operations to
correct recurrent anterior dislocation of the shoulder, is

Deltoid
muscle
Infraspinatus
muscle

Fig. 1-90 Cubbins et al. approach


to anterior, superior, and posterior aspects of shoulder joint. A,
Skin incision. B, Origin of
deltoid reected from clavicle,
acromion, and spine of scapula;
posterior capsule incised vertically. C, Capsule retracted,
exposing posterior portion of
glenoid and humerus.

B
Acromion
process

Glenoid
cavity

Chapter 1 Surgical Techniques and Approaches

discussed in Chapter 45. This approach is indicated when


cosmesis is a factor.
Deltoid-Splitting Approach
The deltoid-splitting approach is appropriate for limited
operations that need only to expose the tendons inserting
on the greater tuberosity of the humerus and to reach the
subdeltoid bursa.

95

Scapular
origin

Acromial
origin
Posterior
border

Clavicular
origin

Operable
area

TECHNIQUE 1-77
Begin the incision at the anterolateral tip of the acromion, and
carry it distally over the deltoid muscle about 5 cm.

Anterior
border

Dene the tendinous interval 4 to 5 cm long between the


anterior and middle thirds of the deltoid; splitting the muscle
here provides a fairly avascular approach to underlying structures.
For maximum exposure, split the deltoid up to the margin of
the acromion, but do not split it distally more than 3.8 cm from
its origin to avoid damaging the axillary nerve and paralyzing the
anterior part of the deltoid (Fig. 1-91). (The axillary nerve courses
transversely just proximal to the midpoint between the lateral
margin of the acromion and the insertion of the deltoid.)
Incise the thin wall of the subdeltoid bursa and explore the
rotator cuff as desired by rotating and abducting the arm to
bring different parts of it into view in the oor of the wound.

A transverse skin incision about 6.5 cm long may be used


instead of the longitudinal one to leave a less conspicuous scar.
Place it about 2.5 cm distal to the inferior border of the
acromion, dissect the skin aps from the underlying deltoid
muscle, and split the muscle in the line of its bers. The rest of
the approach is the same as that just described.
To approach a more posterior aspect, place the skin incision
more laterally, and split the deltoid just beneath it. To maintain a
dry eld, cauterize the intramuscular vessels encountered.

Transacromial Approach
The transacromial approach, derived from the Codman
saber-cut approach and the Kocher posterior approach to
the shoulder, is excellent for surgery of the musculotendinous cuff and for fracture-dislocations of the shoulder.

Axillary
nerve

Insertion

Deep surface of left deltoid showing location of


axillary nerve. Nerve courses transversely at level about 5 cm
distal to origin of muscle. One branch of nerve has been
exposed fully to show that incision that splits muscle, even
in operable area, damages smaller branches of nerve.
Fig. 1-91

To repair the rotator cuff, an oblique osteotomy of the


acromion (Fig. 1-93A) gives enough exposure, and the cosmetic
result is satisfactory; to expose the joint completely, McLaughlin
advises using the osteotomy technique shown in Figure 1-93B. In
either instance, excise the detached segment of the acromion.
Armstrong advises complete acromionectomy (Fig. 1-93C) if
subacromial impingement of the rotator cuff would be a
problem.
To expose the joint, split any of the tendons of the cuff in the
line of their bers or separate two of them; the best way is to
approach between the subscapularis and supraspinatus tendons
through the coracohumeral ligament.
Later close the cuff by side-to-side suture, bevel the stump of
the acromion, and suture the edge of the deltoid to the fascia on
the stump.

TECHNIQUE 1-78 Darrach; McLaughlin


Incise the skin just lateral to the acromioclavicular joint from
the posterior aspect of the acromion superiorly like a shoulder
strap and anteriorly to a point 5 cm distal to the anterior edge of
the acromion (Fig. 1-92).
Deepen the anterior limb through the deltoid muscle, detach
the deltoid from its acromial origin, and divide the
coracoacromial ligament.

Kuz et al. recommended a coronal transacromial osteotomy just anterior to the spine of the scapula and parallel
to it for hemiarthroplasty and total shoulder arthroplasty.
The osteotomy is repaired with two large, absorbable,
1-0, gure-of-eight sutures passed through drill holes. Kuz
et al. reported an 87% union rate using this osteotomy,
with the remainder having a stable, painless, brous
union.

96

Part I General Principles

Deltoid muscle

Osteotomy site A

Skin incision

Subscapularis
muscle

Supraspinatus
muscle

Osteotomy site B

Incision in
coracohumeral ligament

Fig. 1-92 Transacromial approach to shoulder joint. A, Skin incision. B, Fibers of deltoid separated. C, Osteotomy of acromion. D, Line of incision through coracohumeral ligament.
Detached segment of acromion is usually discarded.

Posterior Approaches
Similar posterior approaches to the shoulder joint have
been described by Kocher, McWhorter, Bennett, Rowe
and Yee, Harmon, and others. For any such approach to
be carried out safely, a thorough knowledge of the anatomy
of the posterior aspect of the shoulder is essential (Fig.
1-94).

TECHNIQUE 1-79
Begin the skin incision just lateral to the tip of the acromion,
pass it medially and posteriorly along the border of the
acromion, curve it slightly distal to the spine of the scapula, and
end it at the base of the spine of the scapula (Fig. 1-95A).

Supraspinatus muscle

Suprascapular nerve
Deltoid
muscle

C
Axillary
nerve

Radial
nerve
Triceps
muscle

Infraspinatus
muscle

Lines of osteotomy of acromion. Oblique osteotomy (A) is adequate for repair of ordinary shoulder cuff
lesion. Resection of acromion at B is preferable when complete exposure of shoulder joint is required. Line of osteotomy for complete acromionectomy (C).
Fig. 1-93

Teres minor
muscle

Nerve to
teres minor
muscle

Teres major muscle


Fig. 1-94

Anatomy of posterior aspect of shoulder joint.

Chapter 1 Surgical Techniques and Approaches

97

Infraspinatus muscle
Teres minor muscle
Deltoid
muscle

Deltoid
muscle

Suprascapular nerve

A
Axillary
nerve

Fig. 1-95 Posterior approach to


shoulder joint. A, Deltoid is being
detached from spine of scapula and
from acromion. Inset, Skin incision.
B, Deltoid has been retracted to
expose interval between infraspinatus and teres minor. C, Infraspinatus
and teres minor have been retracted
to expose posterior aspect of joint
capsule. Inset, Relationships of suprascapular and axillary (circumex)
nerves to operative eld.

Capsule
Teres minor muscle

Infraspinatus
muscle

Deltoid muscle

Insertion of long head of


triceps muscle

Reect the skin and fascia, and expose the origin of the
deltoid muscle from the spine of the scapula. Detach this part of
the deltoid from the bone by subperiosteal dissection, and reect
it distally and laterally, taking care to avoid injury to the axillary
nerve and vessels as they emerge from the quadrangular space
and enter the muscle (Fig. 1-95B). As a precaution against
injuring this nerve, do not retract the deltoid distal to the teres
minor muscle, and to avoid injuring the suprascapular nerve, do
not enter the infraspinatus muscle.
After reecting the deltoid, expose the posterior surface of the
joint capsule by detaching the inferior two thirds of the
infraspinatus tendon near its insertion on the humerus and
reecting the detached part medially.

Alternatively, the posterior part of the joint can be exposed by


an oblique incision between the infraspinatus and teres minor
muscles (Fig. 1-95C) and then opening the joint capsule by a
longitudinal or a transverse incision or by a combination of both,
as needed.

Brodsky, Tullos, and Gartsman described a simplied


posterior approach to the shoulder introduced to Tullos by
J.W. King. It is based on the fact that wide abduction of
the arm raises the inferior border of the posterior deltoid
to the level of the glenohumeral joint. This approach can
be used for a wide variety of procedures and does not
require freeing large portions of the posterior deltoid from

98

Part I General Principles

B
Quadrangular space with
posterior humeral circumflex
artery and axillary nerve

Lateral head of
triceps muscle

Deltoid
muscle

Deltoid
muscle

Long head of
triceps muscle

Triangular space
Teres major muscle

Infraspinatus
muscle

Subscapular
nerve

Teres minor muscle

Joint capsule
Teres minor muscle

Infraspinatus muscle

D
Fig. 1-96 Simplied posterior approach. A, Skin incision. B, Posterior deltoid muscle has been
elevated to level of joint by abduction of arm to 90 degrees. C, Deltoid has been retracted
superiorly exposing muscles of rotator cuff. D, Capsule has been exposed. (Modied from
Brodsky JW, Tullos HS, Gartsman GM: Simplied posterior approach to the shoulder joint: a technical
note, J Bone Joint Surg 71A:407, 1989.)

Chapter 1 Surgical Techniques and Approaches

the scapular spine or splitting the deltoid; postoperative


immobilization for healing of the muscle is unnecessary.
Rehabilitation of the shoulder can be started as soon as
tolerated by the patient if the particular procedure performed does not require immobilization.
TECHNIQUE 1-80 King, as described by Brodsky et al.
Place the patient prone or in the lateral position.
Drape the arm and shoulder free, and abduct the shoulder to
90 degrees, but no farther, avoiding excessive traction on the
axillary vessels and brachial plexus.
Begin a vertical incision at the posterior aspect of the
acromion, and carry it inferiorly for 10 cm (Fig. 1-96A and B).
Retract the posterior deltoid superiorly (Fig. 1-96C) and, if
necessary, release the medial 2 cm of its origin from the scapular
spine.
Develop the interval between the infraspinatus and teres
minor muscles.
Incise the capsule of the joint in a manner dependent on the
procedure to be performed; to prevent injury to the axillary nerve
and the posterior humeral circumex vessels beneath the inferior
border of the teres minor, avoid dissecting too far inferiorly (Fig.
1-96D).

Posterior Inverted U Approach


The deltoid muscle has three partsthree heads of origin
and two relatively avascular intervals separating the three.
The anterior part (which originates on the lateral third of
the clavicle and the anterior border of the acromion) and

99

the posterior part are composed primarily of long parallel


muscle bers extending from the origin to the insertion.
The middle part is multipennate, with short bers inserting obliquely into parallel tendinous bands. The interval
between the posterior and middle parts can be found by
beginning the dissection at the angle of the acromion and
proceeding through the brous septum; with care, the
division can be extended distally through the proximal two
thirds of the muscle without endangering the nerve supply,
because the posterior branch of the axillary nerve supplies
the posterior part of the muscle, and the anterior branch
supplies the anterior and middle parts. The interval between
the anterior and middle parts is less distinct; it extends
distally from the anterior apex of the shoulder formed by
the anterolateral tip of the acromion.
In view of this tripartite division, Abbott and Lucas
described inverted U-shaped approaches to reach the anterior, lateral, and posterior aspects of the shoulder joint,
dissecting the deltoid distally at the two intervals described
and detaching the appropriate third of the muscle from its
origin. They, too, warn that to separate the anterior and
middle thirds distally more than 4 to 5 cm endangers the
trunk of the axillary nerve (Fig. 1-97; see also Fig. 1-91).
TECHNIQUE 1-81

Abbott and Lucas

Begin the skin incision 5 cm distal to the spine of the scapula


at the junction of its middle and medial thirds, and extend it
superiorly over the spine and laterally to the angle of the
acromion. Curve the incision distally for about 7.5 cm over the
tendinous interval between the posterior and middle thirds of
the deltoid muscle (Fig. 1-98A).

Axillary nerve

Fig. 1-97 Nerve and blood supply of


deltoid muscle. A, Anterior and posterior divisions of axillary nerve to deltoid
muscle. B, Blood supply of deltoid
muscle from posterior humeral circumex artery and anastomotic branches
from adjacent arteries.

A
Subscapular branch
Acromial branch
of thoracoacromial
artery
Posterior
humeral
circumflex
artery

Deltoid
branch
Anterior
humeral
circumflex
artery

100

Part I General Principles

A
Fig. 1-98 Abbott and Lucas inverted U
approach to posterior aspect of shoulder. A,
Skin incision. B, Skin and muscle ap turned
down, exposing quadrangular space and posterior aspect of rotator cuff and muscles. C,
Rotator cuff and capsule incised, exposing
humeral head.

Axillary
nerve

Capsule

Posterior
humeral
circumflex
artery

B
TECHNIQUE 1-81

Abbott and Lucascontd

Free the deltoid subperiosteally from the spine of the scapula,


split it distally in the interval, and turn the resulting ap of skin
and muscle distally for 5 cm to expose the infraspinatus and teres
minor muscles and the quadrangular space (Fig. 1-98B). The
posterior humeral circumex artery and the axillary nerve each
divide into anterior and posterior branches, so the splitting of the
deltoid between its posterior and middle thirds does not injure
them.
Carry this division of the deltoid to its insertion to give full
access to the quadrangular space if desired.
To expose the glenohumeral joint, incise the shoulder cuff in
its tendinous part, and retract the muscles; then divide the
capsule (Fig. 1-98C).

Humerus
Anterolateral Approach
TECHNIQUE 1-82 Thompson; Henry
Incise the skin in line with the anterior border of the deltoid
muscle from a point midway between its origin and insertion,
distally to the level of its insertion, and proceed in line with the
lateral border of the biceps muscle to within 7.5 cm of the elbow
joint (Fig. 1-99).

C
Divide the supercial and deep fasciae, and ligate the cephalic
vein.
In the proximal part of the wound, retract the deltoid laterally
and the biceps medially to expose the shaft of the humerus.
Distal to the insertion of the deltoid, expose the brachialis
muscle, split it longitudinally to the bone, and retract it
subperiosteally, the lateral half to the lateral side and the medial
half to the medial. Retraction is easier when the tendon of the
brachialis is relaxed by exing the elbow to a right angle. The
lateral half of the brachialis muscle protects the radial nerve as it
winds around the humeral shaft (Fig. 1-100; see also Fig. 1-99).

If desired, the distal end of this approach may be carried


to within 5 cm of the humeral condyles and the proximal
end farther proximally, as in the anteromedial approach to
the shoulder. The advantages of this approach are that the
brachialis muscle usually is innervated by the musculocutaneous and radial nerves and can be split longitudinally
without paralysis, and that the lateral half of the brachialis
muscle protects the radial nerve.
The anterior aspect of the humeral shaft at the junction
of its middle and distal thirds also can be approached
between the biceps and brachialis muscles medially and the
brachioradialis laterally (see Fig. 1-100). In a retrospective
study, King and Johnston reported that the original anterolateral skin incision as described by Henry (Fig. 1-101; see

Chapter 1 Surgical Techniques and Approaches

Deltoid
muscle

Line of
incision

II

Deltoid
muscle

Biceps
muscle

III
Biceps
muscle

Brachialis
muscle

IV
Brachialis
muscle

Fig. 1-99 Anterolateral approach to shaft of humerus. A, Skin incision. B, Deltoid and biceps
muscles retracted; brachialis muscle incised longitudinally, exposing shaft.

Cephalic
vein
Radial
nerve

Cephalic
vein

Deltoid
muscle
Brachialis
muscle

Deltoid
muscle

Radial
nerve

Cephalic
vein

II
Brachialis
muscle

Lateral antebrachial
cutaneous nerve

Brachialis
muscle

Radial
nerve

Brachioradialis
muscle
III

Radial nerve

IV

Cross sections at various levels in arm (see Fig. 1-99) to show approach through
deep structures and relationship to radial nerve.
Fig. 1-100

101

102

Part I General Principles

Brachioradialis
muscle
Incision
Brachialis
muscle

Biceps
muscle

Periosteum

Brachioradialis
muscle

Brachialis muscle

Incision
Brachialis
muscle
Radial nerve

Humerus

Fig. 1-101 Exposure of humerus at junction of middle and distal thirds through anterolateral
approach. A, Skin incision. B, Interval between biceps and brachialis muscles medially and
brachioradialis muscle laterally is developed, and muscles are retracted. C, Radial nerve identied and retracted. D, Nerve is retracted, and brachioradialis and brachialis muscles are separated, exposing humeral shaft.

also Fig. 1-100) frequently transected branches of the lower


lateral brachial cutaneous nerve, resulting in painful
neuroma formation, numbness, or tingling around the
wound scar in 62% of 30 patients. This was conrmed by
an anatomical study of seven cadaver arms. King and
Johnston recommend a more anteriorly placed incision
(Fig. 1-102) in the watershed zone between the lower
lateral brachial and the medial brachial cutaneous nerves.
Posterior Approach to the Proximal Humerus
Berger and Buckwalter described a posterior approach to
the proximal third of the humeral diaphysis for resection
of an osteoid osteoma. This approach exposes the bone
through the interval between the lateral head of the triceps
muscle innervated by the radial nerve and the deltoid
muscle innervated by the axillary nerve. Approximately
8 cm of the bone can be exposed, with the approach limited
proximally by the axillary nerve and posterior circumex

humeral artery and distally by the origin of the triceps


muscle from the lateral border of the spiral groove and by
the underlying radial nerve.

TECHNIQUE 1-83 Berger and Buckwalter


Place the patient in the lateral position with the extremity
draped free and positioned across the patients chest. Beginning
5 cm distal to the posterior aspect of the acromion, make a
straight incision over the interval between the deltoid and triceps
muscles, and extend it distally to the level of the deltoid
tuberosity.
Bluntly develop the interval between the lateral head of the
triceps and the deltoid (Fig. 1-103).
Expose the periosteum of the humerus, and incise it
longitudinally.

Chapter 1 Surgical Techniques and Approaches

Upper lateral
brachial cutaneous
nerve

Lower lateral
brachial cutaneous
nerve

103

Upper lateral
brachial cutaneous
nerve

Intercostobrachial
nerve

Intercostobrachial
nerve
Lower lateral
brachial cutaneous
nerve

Medial brachial
cutaneous nerve

Medial brachial
cutaneous nerve

Fig. 1-102 A, Relationship of lower lateral brachial cutaneous nerve and anterior midline skin
incision. B, Relationship of lower lateral brachial cutaneous nerve and standard Henrys anterolateral skin incision. (From King A, Johnston GH: A modication of Henrys anterior approach to
the humerus, J Shoulder Elbow Surg 7:210, 1998.)

Elevate the periosteum medially, and retract it and the lateral


head of the triceps medially.

Continue the subperiosteal elevation of the triceps proximally


until its origin from the proximal humerus is reached. Retract the
triceps medially with care to avoid injury to the radial nerve as it
comes in contact with the periosteum about 3 cm proximal to
the level of the deltoid tuberosity.
Elevate the periosteum laterally, and retract it and the deltoid
laterally.
To extend the exposure proximally, carefully continue the
subperiosteal dissection to the proximal origin of the lateral head
of the triceps. Protect the axillary nerve and posterior circumex
artery at the proximal edge of this exposure.

To extend the exposure distally, partially release the insertion


of the deltoid muscle carefully, avoiding the radial nerve that is
beneath the lateral border of the triceps (Fig. 1-103).

of the deltoid muscle, one must keep the radial nerve in


mind and avoid its path.
Moran described a modied lateral approach to the
distal humeral shaft for fracture xation. This approach
uses the interval between the triceps and brachioradialis
muscles and does not involve splitting the triceps tendon
or muscle.

Axillary nerve and


posterior humeral
circumflex artery
Radial nerve and
profunda brachii
artery

Humerus
Long head of
triceps muscle

Approaches to the Distal Humeral Shaft


Henry described a posterior approach that splits the triceps
to expose the posterior humeral shaft in its middle two
thirds. This approach is sometimes valuable when excising
tumors that cannot be reached by the anterolateral approach.
Medially the humeral shaft can be approached posterior to
the intermuscular septum along a line extending proximally from the medial epicondyle. The ulnar nerve is freed
from the triceps muscle and retracted medially; the triceps
is then separated from the posterior surface of the medial
intermuscular septum and the adjacent humeral shaft. If
this approach is extended proximally to the inferior margin

Deltoid
muscle

Lateral head of
triceps muscle

Deltoid
tuberosity

Fig. 1-103 Posterior approach to proximal humeral diaphysis. Broken line indicates course of radial nerve beneath lateral
head of triceps muscle (see text). (Modied from Berger RA,
Buckwalter JA: A posterior surgical approach to the proximal part
of the humerus, J Bone Joint Surg 71A:407, 1989.)

104

Part I General Principles

Posterior
antebrachial
cutaneous nerve
Profunda
brachii artery
Radial nerve
Lateral intermuscular
septum
Lateral head of
triceps brachii muscle
Anconeus muscle

Lateral head
of triceps
brachii muscle

Posterior
antebrachial
cutaneous nerve

Posterior
Triceps
brachii muscle

Profunda
brachii artery

Posterior
antebrachial
cutaneous
nerve

Radial nerve
Lateral intermuscular
septum

Lateral
Radial nerve

Anconeus muscle
Brachioradialis
muscle

D
C
Fig. 1-104 Modied lateral approach to the posterior distal humerus. A, Skin incision. B,
Interval between lateral head of triceps and lateral intermuscular septum is developed. C, Medial
retraction of triceps exposes the posterior aspect of the humerus. D, Cross section of upper
arm at midpoint of skin incision. (Modied from Moran MC: Modied lateral approach to the
distal humerus for internal xation, Clin Orthop 340:190, 1997.)

Chapter 1 Surgical Techniques and Approaches

TECHNIQUE 1-84

Moran

Place the patient prone or in the lateral decubitus position.

Table 1-5 Summary of Surgical Approaches


to the Elbow and Proximal Forearm

Make a longitudinal skin incision 15 to 18 cm in length over

Approaches/Author

the posterolateral aspect of the arm (Fig. 1-104A). Extend the


incision distally midway between the lateral epicondyle of the
humerus and the tip of the olecranon 4 cm distal to the elbow
joint. The proximal portion of the incision is located 4 cm
posterior to the lateral intermuscular septum.

Posterior Approaches
Campbell WC
Campbell WC
Extended Kocher/Ewald
Wadsworth TG

From the midpoint of the wound, dissect laterally until the


lateral intermuscular septum is reached.

Bryan RS, Morrey BF

Incise the triceps fascia longitudinally a few millimeters


posterior to the intermuscular septum, and carefully separate the
triceps muscle from the intermuscular septum working distally to
proximally.
Distally, incise the fascia at the lateral edge of the anconeus
and carry this 4 cm distal to the lateral epicondyle.

Retract the anconeus muscle and fascia in continuity with the


triceps.

Identify and protect the posterior antebrachial cutaneous


nerve as it leaves the posterior compartment at the lateral
intermuscular septum (Fig. 1-104B and D).

Retract the radial nerve anteriorly. The radial nerve passes


through the lateral intermuscular septum at the junction of the
middle and distal thirds of the humerus (Fig. 1-104B).
Retract the triceps muscle medially to expose the posterior
humeral shaft (Fig. 1-104C). If more proximal exposure is needed,
carefully follow the radial nerve proximally, and bluntly dissect it
from the region of the spiral groove.

To close the wound, allow the triceps muscle to fall anteriorly


into its bed, and loosely close the fascia with interrupted sutures.

Elbow
There has been a marked increase in information pertaining to surgery of the elbow. Table 1-5 provides a summary
of surgical approaches to the elbow and proximal forearm
as compiled by Mehta and Bain. Only the more commonly
used of these approaches are described here.
Posterolateral Approach
Campbell used a posterolateral approach to the elbow for
extensive operations such as treatment of old posterior dislocations, fractures of the distal humerus involving the
joint, and arthroplasties.
TECHNIQUE 1-85

Campbell

Begin the skin incision 10 cm proximal to the elbow on the


posterolateral aspect of the arm, and continue it distally for
13 cm (Fig. 1-105A).

105

Tissue Plane

Muller ME,
MacAusland WR

Midline triceps split


Triceps aponeurosis tongue
ECU and anconeus/triceps
Triceps aponeurosis tongue and fullthickness deep head
Elevate triceps mechanism from medial
olecranon and reect laterally
Lateral border of triceps/ulna and
anconeus/ECU
Olecranon osteotomytransverse or
chevron

Lateral Approaches
Kocher TE
Cadenat FM
Kaplan EB
Key CA, Conwell HE

Between
Between
Between
Between

Boyd HB

Medial Approach
Hotchkiss R
Molesworth WHL
Global Approach
Patterson SD, Bain G,
Mehta J

Anterior Approach
Henry AK

FCU and anconeus


ECRB and ECRL
ECRB and ECU
BR and ECRL

Between FCU and PL/FCR; brachialis


resected laterally with PL/FCR/PT
Medial epicondyle osteotomy
Kocher interval; lateral epicondyle
osteotomy; Kaplan interval;
Hotchkiss interval; Taylor interval
Between mobile wad and biceps
tendon; elevate supinator from
radius

BR, brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor


carpi radialis longus; ECU, extensor carpi ulnaris; FCR, exor carpi
radialis; FCU, exor carpi ulnaris; FDP, exor digitorum profundus; PL,
palmaris longus; PT, pronator teres.
From Mehta JA, Bain, GI: Surgical approaches to the elbow, Hand Clin
20;375, 2004.

Deepen the dissection through the fascia, and expose the


aponeurosis of the triceps as far distally as its insertion on the
olecranon.
When the triceps muscle has been contracted by xed
extension of the elbow, free the aponeurosis proximally to
distally in a tongue-shaped ap, and retract it distally to its
insertion (Fig. 1-105B); incise the remaining muscle bers to the
bone in the midline.

If the triceps muscle has not been contracted, divide the


muscle and aponeurosis longitudinally in the midline, and
continue the dissection through the periosteum of the humerus,

106

Part I General Principles

Triceps
muscle
Line of
skin incision

Triceps
aponeurosis

Olecranon

Ulnar
nerve

Radial
nerve

Lateral
epicondyle

Radial head
Triceps
aponeurosis

C
Fig. 1-105 Campbell posterolateral approach to elbow joint in contracture of triceps. A, Skin
incision. B, Tongue of triceps aponeurosis has been freed and reected distally. C, Elbow joint
has been exposed by subperiosteal dissection. Ulnar nerve has been identied and protected.

TECHNIQUE 1-85

Campbellcontd

through the joint capsule, and along the lateral border of the
olecranon (Fig. 1-105C).

Elevate the periosteum together with the triceps muscle from


the posterior surface of the distal humerus for 5 cm (Fig. 1-106).
For wider exposure, continue the subperiosteal stripping on
each side, releasing the muscular and capsular attachments to
the condyles and exposing the anterior surface, taking care not
to injure the ulnar nerve.

Strip the periosteum from the bone as conservatively as


possible because serious damage to the blood supply of the
bone causes osteonecrosis. The head of the radius lies in the
distal end of the wound.

When the elbow has been xed in complete extension with a


contracted triceps muscle, it should be exed to a right angle for
closure of the wound. Fill the distal part of the defect in the
triceps tendon with the inverted V-shaped part of the triceps
fascia, and close the proximal part by suturing the remaining two
margins of the triceps.

Long head of
triceps muscle

Ulnar
nerve

Lateral head of
triceps muscle

Brachioradialis
muscle
Extensor carpi
radialis longus
muscle
Anconeus
muscle

Flexor carpi
ulnaris muscle

Extensor carpi
ulnaris muscle

A
Ulna

Humerus

Articular
capsule

Olecranon
Ulnar
nerve

Flexor carpi
ulnaris muscle

Supinator
muscle
Extensor carpi
ulnaris muscle

C
Fig. 1-106 Campbell posterolateral approach to elbow joint. A, Solid line indicates usual skin
incision, and broken line indicates alternative one. B, Incision through deep structures. C,
Proximally, aponeurosis and belly of triceps and periosteum have been divided longitudinally
in midline of limb. Distally, dissection has been continued subperiosteally along lateral side of
olecranon and proximal ulnar shaft. Soft structures have been retracted to expose distal
humerus, proximal ulna, and joint capsule posteriorly.

108

Part I General Principles

Triceps
muscle

Ulnar
nerve

Olecranon
Capitellum

Triceps
tendon

Radius
Ulnar
nerve

Extensor carpi
ulnaris muscle

Anconeus
muscle

Fig. 1-107 Wadsworth extensile posterolateral approach to elbow. A, Skin incision. Right,
Patient is prone with elbow exed 90 degrees and arm supported as shown. B, Distally based
tongue of triceps tendon with intact peripheral rim is fashioned. Ulnar nerve is protected. C,
Exposure is complete (see text). (Redrawn from Wadsworth TG: A modied posterolateral approach
to the elbow and proximal radioulnar joints, Clin Orthop 144:151, 1979.)

Extensile Posterolateral Approach


To achieve the maximum safe exposure of the elbow and
proximal radioulnar joints, Wadsworth modied the known
posterolateral approaches. His extensile approach is useful
for displaced distal humeral articular fractures, synovectomy, total elbow arthroplasty, and other procedures
requiring extensive exposure.

proximally along the triceps tendon, across laterally and distally


through the tendon to the posterior aspect of the lateral
epicondyle. From this point, deviate the incision distally and
medially through the triceps aponeurosis to separate the
anconeus from the extensor carpi ulnaris (Fig. 1-107B).

Divide the posterior capsule in the same line.


Reect the triceps tendon distally, dividing the muscle tissue

TECHNIQUE 1-86 Wadsworth


With the patient prone and the elbow exed 90 degrees over
a support and the forearm dependent, begin a curved skin
incision over the center of the posterior surface of the arm at the
proximal limit of the triceps tendon, and extend it distally to the
posterior aspect of the lateral epicondyle and farther distally and
medially to the posterior border of the ulna, 4 cm distal to the
tip of the olecranon (Fig. 1-107A).

Dissect the medial skin ap far enough medially to expose the


medial epicondyle, and gently elevate the lateral skin ap a short
distance; keep both skin aps retracted with a single suture in
each.
Identify the ulnar nerve proximally, and release it from its
tunnel by dividing the arcuate ligament that passes between the
two heads of the exor carpi ulnaris muscle; gently retract it with
a rubber sling.

To fashion a tongue of triceps tendon with its base attached


to the olecranon, leaving a peripheral tendinous rim attached to
the triceps for later repair, begin sharp dissection at the medial
surface of the proximal part of the olecranon, extend it

with care in an oblique manner for minimal damage to the deep


part of the muscle; stay well clear of the radial nerve.

Reect the anconeus and underlying capsule medially.


Behind the lateral epicondyle, the incision lies between the
anconeus muscle and the common tendinous origin of the
forearm extensor muscles. To increase exposure, partially reect
from the humerus the common extensor origin, the lateral
collateral ligament, and the adjacent capsule.
Excellent exposure is easily achieved (Fig. 1-107C); increase the
exposure by putting a varus strain on the elbow joint.
During closure, repair the triceps tendon, posterior capsule,
and triceps aponeurosis with strong interrupted sutures.

Posterior Approach by Olecranon Osteotomy


In a comparative anatomical study, Wilkinson and Stanley
showed that an olecranon osteotomy exposed signicantly
more articular surface of the distal humerus than a tricepsreecting approach. Olecranon osteotomy did not expose
signicantly more articular surface than a triceps-splitting
approach.

Chapter 1 Surgical Techniques and Approaches

109

4.5 mm
1
3.2 mm
2
6.5 mm
3

Fig. 1-108 Osteotomy of olecranon. A, Preparation of hole for 6.5-mm cancellous screw. B,
Incomplete osteotomy made with thin saw or osteotome. C, Osteotomy completed by cracking
bone. D, Lag screw (6.5 mm) and tension band wire xation. This technique also is useful for
internal xation of olecranon fractures.

TECHNIQUE 1-87 MacAusland and Mller


Expose the elbow posteriorly through an incision beginning
5 cm distal to the tip of the olecranon and extending proximally
medial to the midline of the arm to 10 to 12 cm above the
olecranon tip.

Reect the skin and subcutaneous tissue to either side


carefully to expose the olecranon and triceps tendon.
Expose the distal humerus through a transolecranon approach.

Drill a transverse hole in the ulna distal to the osteotomy site,


and pass a No. 20 wire through this hole around the screw neck,
and tighten it in a gure-of-eight manner (Fig. 1-108D).

Extensile Posterior Approach


Bryan and Morrey developed a modied posterior approach
to the elbow joint that provides excellent exposure and
preserves the continuity of the triceps mechanism, which
allows easy repair and rapid rehabilitation.

Isolate the ulnar nerve, and gently retract it from its bed with
a Penrose drain or a moist tape.

TECHNIQUE 1-88

Drill a hole from the tip of the olecranon down the medullary
canal; then tap the hole with the tap to match a large (6.5-mm)
AO cancellous screw 8 to 10 cm in length (Fig. 1-108A).

Place the patient in the lateral decubitus position or tilted 45


to 60 degrees with sandbags placed under the back and hip.
Place the limb across the chest.

Divide three fourths of the olecranon transversely with an

Make a straight posterior incision in the midline of the limb

osteotome or thin oscillating saw approximately 2 cm from its


tip. Fracture the last fourth of the osteotomy (Fig. 1-108B and C).

extending from 7 cm distal to the tip of the olecranon to 9 cm


proximal to it.

Reect the olecranon and the attached triceps proximally to


give excellent exposure of the posterior aspect of the lower end
of the humerus.

Identify the ulnar nerve proximally at the medial border of the


medial head of the triceps, and dissect it free from its tunnel
distally to its rst motor branch (Fig. 1-109A).

Alternatively, the osteotomy may be done in a chevron fashion


to increase bone surface area for healing and to control rotation

In total joint arthroplasty, transplant the nerve anteriorly into

At wound closure, reduce the proximal fragment and insert a


cancellous screw using the previously drilled and tapped hole in
the medullary canal.

Elevate the medial aspect of the triceps from the humerus,


along the intermuscular septum, to the level of the posterior
capsule.

Bryan and Morrey

the subcutaneous tissue (Fig. 1-109B).

110

Part I General Principles

Olecranon
Medial
epicondyle

Superficial
forearm fascia

Olecranon

Line of incision

Medial
epicondyle

Ulnar
nerve
Triceps
muscle

Ulnar nerve
Triceps
muscle

Flexor carpi
ulnaris muscle

Forearm fascia
ulnar periosteum

Olecranon
Joint capsule
Medial epicondyle
Ulnar nerve
Triceps muscle

C
Anconeus muscle
Ulnar collateral
ligament

Superficial
forearm fascia

Sharpeys
fibers
Radial
head
Medial epicondyle

Ulnar nerve
Olecranon
Cut for
excision of
olecranon
tip

Triceps muscle

D
Fig. 1-109

A-E, Bryan and Morrey extensile posterior approach to elbow (see text).

Ulnar nerve

Chapter 1 Surgical Techniques and Approaches

TECHNIQUE 1-88

Bryan and Morreycontd

Incise the supercial fascia of the forearm distally for about

111

Suture the periosteum to the supercial forearm fascia, as far


as the margin of the exor carpi ulnaris (Fig. 1-109E).

6 cm to the periosteum of the medial aspect of the olecranon.

Close the wound in layers, and leave a drain in the wound. In

Carefully reect as a single unit the periosteum and fascia


medially to laterally (Fig. 1-109C). The medial part of the junction
between the triceps insertion and the supercial fascia and the
periosteum of the ulna is the weakest portion of the reected
tissue. Take care to maintain continuity of the triceps mechanism
at this point; carefully dissect the triceps tendon from the
olecranon when the elbow is extended to 20 to 30 degrees to
relieve tension on the tissues, and then reect the remaining
portion of the triceps mechanism.

total joint arthroplasty, dress the elbow with the joint exed
about 60 degrees to avoid direct pressure on the wound by the
olecranon tip.

To expose the radial head, reect the anconeus subperiosteally


from the proximal ulna; the entire joint is now widely exposed
(Fig. 1-109D).
The posterior capsule usually is reected with the triceps
mechanism, and the tip of the olecranon may be resected to
expose the trochlea clearly (see Fig. 1-109D).

To attain joint retraction in total joint arthroplasty, release the


medial collateral ligament from the humerus if necessary.
During closure, carefully repair the medial collateral ligament
when its release has been necessary.

Return the triceps to its anatomical position and suture it


directly to the bone through holes drilled in the proximal aspect
of the ulna.

Lateral Approach
The lateral approach is an excellent approach to a fracture
of the lateral condyle, because the common origin of the
extensor muscles is attached to the condylar fragment and
need not be disturbed.
TECHNIQUE 1-89
Begin the incision approximately 5 cm proximal to the lateral
epicondyle of the humerus, and carry it distally to the epicondyle
and along the anterolateral surface of the forearm for
approximately 5 cm.
To expose the lateral border of the humerus, develop distally
to proximally the interval between the triceps posteriorly and the
origins of the extensor carpi radialis longus and brachioradialis
anteriorly. In the proximal angle of the wound, avoid the radial
nerve where it enters the interval between the brachialis and
brachioradialis muscles (Fig. 1-110).
Radial nerve
Brachioradialis muscle
Extensor carpi radialis
longus and brevis muscles

Biceps brachii muscle


Brachialis muscle
Radial nerve
Brachioradialis
muscle
Extensor carpi
radialis longus
muscle
Dorsal antebrachial
cutaneous nerve

Triceps
brachii
muscle

Biceps brachii muscle


Brachialis muscle
Radial nerve
Brachioradialis
muscle
Extensor carpi
radialis longus
muscle

Dorsal antebrachial
cutaneous nerve

Triceps
brachii
muscle

Common extensor tendon


Incision

Fig. 1-110 Lateral approach to


elbow joint. A, Cross section
shows approach at level of proximal part of incision; right, skin
incision and its relation to deep
structures. B, Cross section
shows approach at level just
proximal to humeral condyles;
right,
approach
has
been
completed.

112

Part I General Principles

TECHNIQUE 1-89contd

Reect the anconeus subperiosteally from the proximal ulna to

With a small osteotome, separate the common origin of the


extensor muscles from the lateral epicondyle together with a thin
ake of bone, or divide this origin just distal to the lateral
epicondyle.

Reect the common origin distally, and expose the


radiohumeral joint. Protect the deep branch of the radial nerve
as it enters the supinator muscle.
Elevate subperiosteally the origins of the brachioradialis and
extensor carpi radialis longus muscles, and incise the capsule to
expose the lateral aspect of the elbow joint.

Lateral J Approach
TECHNIQUE 1-90 Kocher
Begin the incision 5 cm proximal to the elbow over the lateral
supracondylar ridge of the humerus, extend it distally along this
ridge, continue it 5 cm distal to the radial head, and curve it
medially and posteriorly to end at the posterior border of the
ulna (Fig. 1-111A).

Dissect between the triceps muscle posteriorly and the


brachioradialis and extensor carpi radialis longus muscles
anteriorly to expose the lateral condyle and the capsule over the
lateral surface of the radial head.
Distal to the head, separate the extensor carpi ulnaris from the
anconeus and divide the distal bers of the anconeus in line with
the curved and transverse parts of the distal skin incision. Reect
the periosteum from the anterior and posterior surfaces of the
distal humerus.

Reect anteriorly the common origin of the extensor muscles


from the lateral epicondyle by subperiosteal dissection or by
detachment of the epicondyle.
Incise the joint capsule longitudinally.

dislocate and examine the joint under direct vision (Fig. 1-111B).

Medial Approach with Osteotomy of the Medial


Epicondyle
The medial approach with osteotomy of the medial epicondyle was developed by Molesworth and Campbell,
working independently of each other. Each needed to treat
a fracture of the medial humeral epicondyle. In Campbells
patient, the fragment had been displaced distally and laterally into the joint cavity, carrying with it the attachments
of the forearm exors and part of the medial capsule so
that these interposed between the semilunar notch of the
ulna and the trochlea of the humerus. During surgery,
Campbell found the radius and ulna could be dislocated on
the humerus so that all parts of the joint, including all the
articular surfaces, could be inspected. He used this method
later to remove loose bodies and in other operations that
required gaining access to the interior of the joint.
TECHNIQUE 1-91 Molesworth; Campbell, Fig. 1-112
With the elbow exed to a right angle, make a medial incision
over the tip of the medial epicondyle from 5 cm distal to the
joint to about 5 cm proximal to it.
Isolate the ulnar nerve in its groove posterior to the
epicondyle, free it, and retract it posteriorly.
Dissect all the soft tissues from the epicondyle except the
common origin of the exor muscles, detach the epicondyle with
a small osteotome, and reect it distally together with its
undisturbed tendinous attachments.

By blunt dissection, continue distally, reecting the muscles


that originate from the medial epicondyle. Protect the branches
of the median nerve that supply these muscles, entering along
their lateral margins.

Biceps muscle
Brachioradialis muscle
Extensor carpi radialis
longus muscle

Triceps muscle

Lateral
epicondyle

Line of skin incision


Anconeus muscle

Extensor carpi ulnaris


muscle

Olecranon

Radial head

Fig. 1-111 Kocher lateral J approach to elbow joint. A, Skin incision. B, Approach has been
completed, and elbow joint has been dislocated.

Chapter 1 Surgical Techniques and Approaches

113

Ulnar nerve
Medial epicondyle
Line of skin incision

Common flexor tendon

Line of incision
in capsule

Trochlea of
humerus
Medial epicondyle

Trochlear notch
of ulna

Fig. 1-112 Campbell medial approach to elbow joint. A, Skin incision. B, Ulnar nerve has
been retracted posteriorly, and medial epicondyle is being freed. C, Epicondyle and attached
common origin of exor muscles have been reected distally. Joint capsule is to be incised
longitudinally. D, Approach has been completed, and elbow joint has been dislocated.

Free the medial aspect of the coronoid process, incise the


capsule, and strip the periosteum and capsule anteriorly and
posteriorly from the humerus as far proximally as necessary.
Avoid injuring the median nerve, which passes over the anterior
aspect of the joint.
With the lateral capsule acting as a hinge, dislocate the joint.

Medial and Lateral Approach


TECHNIQUE 1-92
When extensive exposure is not needed, an incision 5 to 7 cm
long can be made on either or both sides of the joint just
anterior to the condyles and parallel with the epicondylar ridges
of the humerus. The exion crease of the elbow is proximal to
the joint line (Fig. 1-113). On the medial side, carefully avoid the
ulnar nerve.
Incise the capsule from proximal to distal on each side.

Fig. 1-113 Kirschner wire has been taped along exion


crease of elbow. Note relation of wire to joint line.

114

Part I General Principles

Global Approach
The global approach allows circumferential exposure of
the elbow. The collateral ligaments, coronoid process, and
anterior joint capsule can be reached through this
approach.

If the medial aspect of the elbow is to be exposed, open the


cubital tunnel, isolate the ulnar nerve, and transpose it anteriorly.
Protect it throughout the procedure with a Penrose drain (Fig.
1-114A).

Develop full-thickness medial or lateral fasciocutaneous aps,


depending on the procedure to be performed.

TECHNIQUE 1-93 Patterson, King, and Bain


POSTEROLATERAL APPROACH

Make a straight posterior midline incision.

Develop the Kocher interval between the anconeus and


extensor carpi ulnaris muscle to expose the elbow capsule and
lateral epicondyle.

Sharply dissect down through the deep fascia to the triceps


tendon and subcutaneous border of the ulna.

Triceps and
anconeus
muscle
Extensor carpi
ulnaris muscle

Radial
collateral
ligament

Lateral ulnar
collateral
ligament

Ulnar nerve

Capsulotomy
anterior to
lateral ulnar
collateral
ligament
Annular ligament

A
B
Step-cut incision
in annular ligament
Chevron
osteotomy
of lateral
epicondyle
Extensor carpi ulnaris
muscle and lateral
epicondyle osteotomy
Retracted triceps
tendon

Retracted
anconeus
muscle

Subperiosteal release
of supinator muscle

Fig. 1-114 Global approach to elbow joint. A, Initial incision and isolation of ulnar nerve.
B, Lateral component. C, Chevron osteotomy of lateral epicondyle.

Chapter 1 Surgical Techniques and Approaches

To expose the olecranon fossa and posterior aspect of the


distal humerus, reect the anconeus and triceps medially.
To expose the radial head, elevate the common extensor origin
anteriorly from the underlying capsule, lateral ulnar collateral
ligament, and lateral epicondyle (Fig. 1-114B).

115

interosseous nerve anteriorly (Fig. 1-114D), and divide the annular


ligament 5 mm from the edge of the lesser sigmoid notch (see
Fig. 1-114C). Elevate a posterior capsular ap if needed. This
violates the lateral ulnar collateral ligament, which must be
repaired at closing.

ulnar collateral ligament, and carry it distally, dividing the annular


ligament.

Release the supinator muscle from the supinator crest of the


ulna, and retract it along with the posterior interosseous nerve to
expose the proximal radius.

If additional exposure of the radial head is needed, perform a

POSTEROMEDIAL APPROACH

Make an arthrotomy along the anterior border of the lateral

chevron osteotomy of the lateral epicondyle (Fig. 1-114C).

Predrill and tap holes to accept one or two 4-mm cancellous


or 3.5-mm cortical screws. Use a small sagittal saw or osteotome
to perform the cut.

Elevate the muscles from the supracondylar ridge


subperiosteally, keeping them in continuity with the lateral
epicondyle and the common extensor origin.

Develop the interval between the extensor digitorum


communis and extensor carpi radialis longus and brevis to the
level of the deep radial (posterior interosseous) nerve where it
enters the supinator at the arcade of Frohse. This allows
reection of the common extensor origin, lateral ulnar collateral
ligament, and attached lateral epicondyle in an anterior and
distal direction.
If additional exposure of the radial head, neck, and proximal
shaft is needed, pronate the forearm to translate the posterior

To extend the approach medially, release the exor carpi


ulnaris and exor digitorum profundus muscles subperiosteally
from their ulnar origins.
Retract anteriorly to expose the coronoid process, anterior
bundle of the medial ligament complex, and anterior joint
capsule (Fig. 1-114E).

Radius
Posterolateral Approach to the Radial Head
and Neck
A posterolateral oblique approach safely exposes the radial
head and neck; it corresponds to the distal limb of the
lateral J approach of Kocher to the elbow. It is the best
approach for excising the radial head, because it is not only
Posterior interosseous
nerve

Radial nerve

Ulnar nerve
Flexor carpi
ulnaris muscle

Medial
epicondyle
Flexor digitorum
profundus muscle

Strip of deep fascia for


repair of flexor attachments

Capsulotomy anterior
to medial collateral
ligament
Triceps tendon

Fig. 1-114, contd D, Translation of posterior interosseous nerve with forearm pronation.
E, Medial component. (Modied from Bain GI, Mehta JA: Anatomy of the elbow joint and surgical
approaches. In Baker CL Jr, Plancher KD, eds: Operative strategies of the elbow, New York, 2001,
Springer-Verlag.)

116

Part I General Principles

extensile proximally and distally without danger to major


vessels or nerves, but it also preserves the nerve supply to
the anconeus. It is safer than an approach that separates the
extensor carpi ulnaris from the extensor digitorum communis or one that separates the latter muscle from the radial
extensors, because both of these endanger the posterior
interosseous nerve. After experimental work on cadavers,
Strachan and Ellis recommend a position of full pronation
of the forearm for maximum protection of the nerve during
this procedure.

Divide the subcutaneous tissue and deep fascia along the line
of the incision, and develop the fascial plane between the
extensor carpi ulnaris and the anconeus muscles. This plane can
be found more easily in the distal than in the proximal part of
the incision, because in the proximal part, the two muscles blend
together at their origin.
Retract the anconeus toward the ulnar side and the extensor
carpi ulnaris toward the radial side, exposing the joint capsule in
the depth of the proximal part of the wound.

TECHNIQUE 1-94

Fibers of the supinator cross at a right angle to the wound,


near its center and deep (anterior) to the extensor carpi ulnaris;
retract the proximal bers of the supinator distally.

Begin an oblique incision over the posterior surface of the


lateral humeral condyle, and continue it obliquely distally and
medially to a point over the posterior border of the ulna 3 to
5 cm distal to the tip of the olecranon (Fig. 1-115).

Locate the joint capsule in the depth of the wound, incise it,
and expose the head and neck of the radius (see Fig. 1-115). The
deep branch of the radial nerve that lies between the two planes
of the supinator remains undisturbed.

Biceps muscle

Brachialis muscle

Brachioradialis muscle
Radial
nerve
Extensor
carpi radialis
longus and brevis
muscles

Flexor
carpi ulnaris
muscle
Anconeus
muscle
Extensor
carpi ulnaris
muscle
Extensor
digitorum
communis
muscle

Radial
nerve
Extensor
carpi radialis
longus and brevis
muscles

Ulnar nerve

Dorsal antebrachial
cutaneous nerve
Common extensor tendon

Olecranon
Anconeus muscle
Approach

Fig. 1-115 Posterolateral approach to head of radius. Cross section shows relationship of surgical
dissection to adjacent anatomy.

Chapter 1 Surgical Techniques and Approaches

Approach to the Proximal and Middle Thirds of


the Posterior Surface
Exposing the proximal third of the radius is difcult
because the deep branch of the radial nerve (posterior
interosseous) traverses it within the supinator muscle; one
must keep this nerve constantly in mind and take care to
protect it from injury.

TECHNIQUE 1-95

Thompson

Make the skin incision over the proximal and middle thirds of
the radius along a line drawn from the center of the dorsum of
the wrist to a point 1.5 cm anterior to the lateral humeral
epicondyle (Fig. 1-116); when the forearm is pronated, this line is
nearly straight.

Expose the lateral (radial) border of the extensor digitorum


communis muscle in the distal part of the incision.

Develop the interval between this muscle and the extensor


carpi radialis brevis, and retract these structures to the ulnar and
radial sides.
The abductor pollicis longus muscle is visible; retract it distally
and toward the ulna to expose part of the posterior surface of
the radius.
Continue the dissection proximally between the extensor
digitorum communis and the extensors carpi radialis brevis and
longus to the lateral humeral epicondyle.

Reect the extensor digitorum communis toward the ulna to


expose the supinator muscle, or for a wider view, detach the
extensor digitorum from its origin on the lateral epicondyle and
retract it further medially.
Expose the part of the radius covered by the supinator by one
of two means. Either divide the muscle bers down to the deep
branch of the radial nerve and carefully retract the nerve, or
free the muscle from the bone subperiosteally and reect it
proximally or distally along with the nerve; the latter is the better
method if the exposure is wide enough.

Anterolateral Approach to the Proximal Shaft and


Elbow Joint
TECHNIQUE 1-96 Henry
With the forearm supinated, begin a serpentine longitudinal
incision at a point just lateral and proximal to the biceps tendon,
and extend it distally in the forearm along the medial border of
the brachioradialis and, if necessary, as far as the radial styloid
(Fig. 1-117A).

Expose the biceps tendon by incising the deep fascia on its


lateral side; divide the deep fascia of the forearm in line with the
skin incision, taking care to protect the radial vessels (Fig. 1-117B
and C).

117

Isolate and ligate the recurrent radial artery and vein


immediately; otherwise, the cut ends may retract, resulting in a
hematoma that may cause ischemic (Volkmann) contracture of
the forearm exor muscles. Flex the elbow to a right angle to
allow more complete retraction of the brachioradialis and the
radial carpal extensor muscles to expose the supinator.
Incise the bicipital bursa, which lies in the angle between the
lateral margin of the biceps tendon and the radius, and from this
point distally, strip the supinator subperiosteally from the radius
and reect it laterally; it carries with it and protects the deep
branch of the radial nerve (Fig. 1-117D and E).
Pronate the forearm and expose the radius by subperiosteal
dissection.

Anterior Approach to the Distal Half of the


Radius
The volar (anterior) surface of the distal half of the radius
is broad, at, and smooth and provides a more satisfactory
bed for a plate or a graft than does the dorsal (posterior)
convex surface.
TECHNIQUE 1-97

Henry

With the forearm in supination, make a 15- to 20-cm


longitudinal incision over the interval between the brachioradialis
and the exor carpi radialis muscles (Fig. 1-118A to C); this
interval, as Kocher stated, lies in the frontier line between the
structures innervated by the different nerves.
Identify and protect the sensory branch of the radial nerve,
which lies beneath the brachioradialis muscle. Carefully mobilize
and retract medially the exor carpi radialis tendon and the radial
artery and vein. The exor digitorum sublimis, exor pollicis
longus, and pronator quadratus muscles are now exposed.

Beginning at the anterolateral edge of the radius, elevate


subperiosteally the exor pollicis longus and the pronator
quadratus muscles (Fig. 1-118D to F), and strip them medially
(toward the ulna).

Ulna
Because part of the posterior surface of the ulna throughout
its length lies just under the skin, any part of the bone can
be approached by incising the skin, fascia, and periosteum
along this surface.
Approaches to the Proximal Third of the Ulna and
the Proximal Fourth of the Radius
The following approach is especially useful when treating
fractures of the proximal third of the ulna associated with
dislocation of the radial head. It also can be used to expose
the proximal fourth of the radius alone, with less danger
to the deep branch of the radial nerve than with other
approaches.

Triceps muscle

Brachialis
muscle
Brachioradialis muscle
Extensor carpi radialis
longus muscle

Interosseous
branch of
radial nerve

Line of incision in
supinator muscle
Supinator muscle

Dorsal
interosseous
artery
Extensor digitorum
communis muscle

Extensor carpi radialis


brevis muscle
Pronator teres muscle
(insertion)

Abductor pollicis
longus muscle

Extensor indicis
proprius muscle

Extensor pollicis
brevis muscle
Extensor pollicis
longus muscle

Supinator muscle
(cut)

Fig. 1-116 Thompson approach to proximal and middle


thirds of posterior surface of radius. A, Skin incision. B,
Relationships of supinator and deep branch of radial nerve
to proximal third of radius. C, Approach has been
completed.

Extensor
digitorum
communis
muscle

Abductor pollicis
longus muscle

Radius
Extensor carpi radialis
brevis muscle

Pronator teres muscle


(insertion)

Chapter 1 Surgical Techniques and Approaches

Biceps
muscle
Brachialis
muscle
Brachioradialis
muscle

Incision

Median nerve

Radial
artery

Pronator teres
muscle

Brachioradialis
muscle

Biceps
muscle
Brachialis muscle

Radial nerve
Fascia
Recurrent
radial artery

Biceps muscle
Radial nerve

Supinator
muscle

Brachialis muscle

Muscular branch of
radial artery

Brachioradialis muscle
Sensory branch of radial nerve

Sensory branch of
radial nerve

Interosseous branch of radial nerve

C
Capsule
Biceps tendon
Radial artery
Supinator
muscle
Incision

Incision in
capsule opened
Capitellum
Annular
ligament

Pronator teres
muscle

Supinator reflected
Radius
Periosteum reflected

E
Fig. 1-117 Modied Henry anterolateral approach to elbow joint. A, Incision. B, Fascia has
been incised to expose brachioradialis laterally and biceps and brachialis medially. Lacertus
brosus has been divided to permit dissection to be deepened between biceps tendon and pronator teres medially and brachioradialis laterally. C, Dissection has been deepened to expose
radial nerve. Nerve and its sensory branch are protected, and recurrent radial artery is ligated
and divided. D, Broken line represents incision to be made through joint capsule and along
medial border of supinator to expose capitellum and proximal radius. E, Forearm has been
supinated, and approach has been completed by reecting supinator. Radial nerve, which courses
in supinator, is protected.

119

120

Part I General Principles

Radial artery

Incision

Brachioradialis muscle

Flexor carpi
radialis muscle

B
Brachioradialis
muscle

Sensory branch of
radial nerve
Tendon of
extensor carpi
radialis longus
muscle

Flexor pollicis
longus muscle

Pronator
quadratus
muscle

Flexor digitorum
sublimus muscle
Radial artery

Flexor carpi radialis muscle

Incision in periosteum
Brachioradialis
muscle
Sensory branch
of radial nerve

Radius
Flexor pollicis
longus muscle

Radial artery

Flexor pollicis
longus muscle

Flexor digitorum
sublimus muscle

Flexor digitorum
sublimus muscle

F
Fig. 1-118 Henry anterior approach to distal half of radius. A, Skin incision. B, Fascia has
been incised, and brachioradialis has been retracted laterally and exor carpi radialis medially.
Radial artery and sensory branch of radial nerve must be protected because they course deep
to brachioradialis. C, Radial vessels and exor carpi radialis tendon have been retracted medially to expose long exor muscles of thumb and ngers and pronator quadratus. D, Forearm
has been pronated to expose radius lateral to pronator quadratus and exor pollicis longus. E,
Broken line indicates incision to be made through periosteum. F, Periosteum has been incised,
and exor pollicis longus and pronator quadratus have been elevated subperiosteally from
anterior surface of radius.

TECHNIQUE 1-98 Boyd


Begin the incision about 2.5 cm proximal to the elbow joint
just lateral to the triceps tendon, continue it distally over the
lateral side of the tip of the olecranon and along the
subcutaneous border of the ulna, and end it at the junction of
the proximal and middle thirds of the ulna (Fig. 1-119A).

Develop the interval between the ulna on the medial


side and the anconeus and extensor carpi ulnaris on the
lateral side.
Strip the anconeus from the bone subperiosteally in the
proximal part of the incision; to expose the radial head, reect
the anconeus radially.

Anconeus muscle
Extensor carpi ulnaris muscle
Triceps tendon

Flexor digitorum
profundus muscle

Olecranon
Reflected portion of supinator muscle from ulna
Reflected portion of supinator muscle from radius
Reflected
anconeus
muscle

Divided portion of
supinator muscle

B
Radial nerve
(deep branch)
entering supinator
muscle

Supinator muscle
Exodus of nerve
from supinator

Flexor
digitorum
profundus
muscle

Olecranon
Incision

Anconeus
muscle
3

Radial nerve

Radial nerve
Flexor
digitorum
profundus
muscle

Recurrent interosseous
artery
Dorsal interosseous
artery

Supinator
muscle
Extensor carpi
ulnaris muscle
Incision
Anconeus muscle

Interosseous
membrane

Ulna
Flexor
digitorum
profundus
muscle

Flexor
digitorum
profundus
muscle

Radial nerve

Radial nerve
Incision
Anconeus muscle

Supinator muscle
Extensor carpi
ulnaris muscle

Supinator muscle
Incision

Recurrent interosseous
artery
Anconeus muscle

Fig. 1-119 Boyd


approach to
proximal third of ulna and fourth
of radius. A, Skin incision. B,
Approach has been completed. C
and D, Relationship of deep
branch of radial nerve to supercial and deep parts of supinator.
C, Numbers 1, 2, 3, and 4 correspond to levels of cross sections in
D with same numbers.

122

Part I General Principles

TECHNIQUE 1-98 Boydcontd


Distal to the radial head, deepen the dissection to the
interosseous membrane after reecting the part of the supinator
that arises from the ulna subperiosteally.
Peel the supinator from the proximal fourth of the radius, and
reect radially the entire muscle mass, including this muscle, the
anconeus, and the proximal part of the extensor carpi ulnaris
(Fig. 1-119B). This amply exposes the lateral surface of the ulna
and the proximal fourth of the radius. The substance of the
reected supinator protects the deep branch of the radial nerve
(Fig. 1-119C and D).
In the proximal part of the wound, divide the recurrent
interosseous artery, but not the dorsal interosseous artery.

TECHNIQUE 1-99

Retract the skin and the supercial and deep fasciae, and
retract the tendons as described in the rst technique, exposing
the radial side of the dorsum of the wrist.
To expose the ulnar side, make a longitudinal incision through
the dorsal carpal ligament between the extensor digiti quinti
proprius and the common extensor tendons. Retract the
common extensor tendons to the radial side and the tendons of
the extensor digiti quinti proprius and extensor carpi ulnaris to
the ulnar side, and incise the capsule transversely.
By combining these deeper incisions and alternately
retracting the tendons of the common extensors of the ngers
to the radial or ulnar side, one may reach the entire dorsal
aspect of the joint.

Gordon

In Monteggia fractures with comminution of the proximal


ulna, Gordon has used an incision that preserves the attachment
of the anconeus to the major loose fragment of the ulna. He
combined two approaches: the approach made between the
anconeus and the extensor carpi ulnaris (see Fig. 1-115), which
exposes the radial head, and the distal part of the Boyd
approach (see Fig. 1-119), which exposes the ulnar shaft. The
osseous attachments of the anconeus, which are severed in the
Boyd approach, are left intact.

Extensor digiti
minimi proprius
tendon
Extensor carpi
ulnaris tendon
Extensor pollicis
longus tendon

Wrist
Dorsal Approaches

Extensor digitorum
communis muscle

TECHNIQUE 1-100
Through a 10-cm dorsal curvilinear incision centered over the
Lister tubercle (Fig. 1-120A), expose the dorsal carpal ligament,
and dene the brous partitions separating the tendon sheaths
on the dorsum of the radius and ulna.

Divide this ligament and the underlying periosteum over the


tubercle, taking care not to injure the tendon of the extensor
pollicis longus; dissect between the extensor tendons of the
thumb and ngers.

Lunate

Scaphoid

Elevate the periosteum of the distal inch of the radius, but


preserve as much as possible of the extensor tendon sheaths.
Retract the extensor tendons of the ngers medially (toward
the ulna) to expose the dorsum of the wrist joint and to allow
transverse incision of the capsule.

TECHNIQUE 1-101
Begin a transverse curved skin incision on the medial side of
the head of the ulna, and extend it across the dorsum of the
wrist to a point 1.5 cm proximal and posterior to the radial
styloid (Fig. 1-120B).

Radius

B
Fig. 1-120 Dorsal approaches to wrist. A, Solid lines represent
curved longitudinal and transverse skin incisions. Broken lines
represent incisions through dorsal carpal ligament (see text).
B, Scaphoid, lunate, and distal radius have been exposed
through curved transverse skin incision and through incision
in dorsal carpal ligament centered over Lister tubercle.

Chapter 1 Surgical Techniques and Approaches

Volar Approach
The volar approach often is used to remove or to reduce a
dislocated lunate.

123

incision has been used but is less desirable because crossing the
exor creases produces a scar that may cause a exion
contracture.)

Incise and retract the supercial and deep fasciae.

TECHNIQUE 1-102
Make a transverse incision across the volar aspect of the wrist
in the distal exor crease (Fig. 1-121). (A curved longitudinal

Identify the palmaris longus tendon. Find and isolate the


median nerve; it is usually deep to the palmaris longus tendon
and slightly to its radial side. In patients with congenital
absence of the palmaris longus tendon, the median nerve is the
most supercial longitudinal structure on the volar aspect of the
wrist. Gently retract the palmaris longus tendon (if present) and
the exor pollicis longus tendon to the radial side. Retract the
exor digitorum sublimis and profundus tendons to the ulnar
side.
Incise the joint capsule, exposing the distal end of the radius
and the lunate.

Lateral Approach
Curved
longitudinal
incision

TECHNIQUE 1-103
Make a 7.5-cm longitudinal skin incision shaped like a bayonet

Transverse incision
through distal
flexor crease

Median
nerve
Palmaris
longus tendon

A
Flexor
tendons

Palmaris
longus tendon

on the radial side of the wrist (Fig. 1-122).

Retract to the volar side of the wrist the extensor pollicis brevis
tendon, the abductor tendons of the thumb, the radial artery,
and the lateral terminal branch of the supercial branch of the
radial nerve; retract the extensor pollicis longus tendon dorsally.
This retraction exposes the tubercle of the scaphoid.
Superficial radial
nerve

Incision

Median
nerve

Extensor pollicis
longus tendon
Radial artery
Abductor pollicis
longus tendon

Scaphoid

A
Lunate

Extensor pollicis
brevis tendon

Median nerve
Palmaris
longus tendon

Scaphoid
Greater multangular

Radius

B
Fig. 1-121 Volar approach to wrist. A, Optional transverse
or curved longitudinal skin incisions. B, Flexor tendons and
median nerve retracted as in cross section, exposing lunate
bone and distal end of radius.

B
Fig. 1-122 Lateral approach to wrist joint. A, Skin incision.
B, Approach has been completed.

124

Part I General Principles

Ulna

LIne of skin
incision

Ulna

Radius
Periosteum

B
Incision in
periosteum of radius

Reflected
periosteum

Radius
Ulnar stump

Radius

Carpus

Fig. 1-123 Smith-Petersen medial approach to wrist. A, Medial curvilinear incision. B, Ulna
osteotomized obliquely 2.5 cm proximal to styloid process. C, Distal ulna resected and
periosteum of radius incised. D, Radiocarpal joint exposed by reection of capsule and
ligaments from carpus and distal end of radius.

TECHNIQUE 1-103contd
Longitudinally divide the radial collateral ligament and capsule
to expose the lateral aspect of the wrist joint. Take care to
protect the radial artery, which passes between the abductor
pollicis longus and the extensor pollicis brevis tendons laterally
and the radial collateral ligament medially, and the supercial
branches of the radial nerve, which supply the skin on the
dorsum of the thumb.

Incise the fascia, and open the capsule longitudinally. Do not


injure the triangular brocartilage attached to the ulnar styloid.

Hand
Surgical approaches to the hand are discussed in Chapter
61.

References
Medial Approach
The medial approach may be used for arthrodesis of the
wrist when tendon transfers around the dorsum of the wrist
are contemplated (see Chapter 68). Smith-Petersen used it
for arthrodesis of the wrist when the distal radioulnar joint
was diseased or deranged; in his technique (Fig. 1-123),
the distal 2.5 cm of the ulna is resected.
TECHNIQUE 1-104
Make a medial curvilinear incision centered over the ulnar
styloid (Fig. 1-123A). Its proximal limb is parallel to the ulna; at
the level of the ulnar styloid, it curves dorsally and toward the
palm toward the proximal end of the fth metacarpal, and its
distal limb parallels the fth metacarpal for about 2.5 cm. While
incising the skin and subcutaneous tissue, carefully avoid injuring
the dorsal branch of the ulnar nerve, which winds around the
dorsum of the wrist immediately distal to the head of the ulna
and divides into its three cutaneous branches supplying the little
nger and the ulnar half of the ring nger.

Surgical Techniques
Aho K, Sainio K, Kianta M, et al: Pneumatic tourniquet paralysis: case report, J Bone Joint Surg 65B:441, 1983.
Albee FH, Kushner A: Bone graft surgery in disease: injury and
deformity, New York, 1940, D Appleton-Century.
American Academy of Orthopaedic Surgeons Task Force on
AIDS and Orthopaedic Surgery: Recommendations for the prevention of human immunode ciency virus (HIV) transmission in the
practice of orthopaedic surgery, Chicago, 1989, The Academy.
American Association of Tissue Banks: Standards for tissue banking
1984, Arlington, Va, 1984, The Association.
Angus PD, Nakielny R, Goodrum DT: The pneumatic tourniquet and deep venous thrombosis, J Bone Joint Surg 65B:336,
1983.
Boyd HB: Congenital pseudarthrosis: treatment by dual bone
grafts, J Bone Joint Surg 23:497, 1941.
Boyd HB: The treatment of difcult and unusual nonunions,
with special reference to the bridging of defects, J Bone Joint
Surg 25:535, 1943.
Braithwaite J, Klenermaw L: Burns under tourniquets: Bruners
ten rules revisited, J Med Der Unions 12:14, 1996.
Brown AR, Taylor GJS, Gregg PJ: Air contamination during
skin preparation and draping in joint replacement surgery, J
Bone Joint Surg 78B:92, 1996.

Chapter 1 Surgical Techniques and Approaches

Bucholz RW, Carlton A, Holmes RE: Hydroxyapatite and tricalcium phosphate bone graft substitutes, Orthop Clin North Am
18:323, 1987.
Bucholz RW, Carlton A, Holmes R: Interporous hydroxyapatite
as a bone graft substitute in tibial plateau fractures, Clin Orthop
Relat Res 240:53, 1989.
Buck BE, Malinin TE, Brown MD: Bone transplantation and
human immunodeciency virus: an estimate of risk of acquired
immunodeciency syndrome (AIDS), Clin Orthop Relat Res
240:129, 1989.
Buck BE, Malinin TI: Human bone and tissue allografts, Clin
Orthop Relat Res 303:8, 1994.
Bunnell S, ed: Surgery of the hand, 2nd ed, Philadelphia, 1948,
JB Lippincott.
Burchardt H: Biology of bone transplantation, Orthop Clin North
Am 18:198, 1987.
Campbell WC: Ununited fractures, Arch Surg 8:782, 1924.
Chapman MW, Bucholz R, Cornell CN: Treatment of acute
fractures with a collagen calcium phosphate graft material:
a randomized clinical trial, J Bone Joint Surg 79A:495,
1997.
Cobden RH, Thrasher EL, Harris WH: Topical hemostatic
agents to reduce bleeding from cancellous bone, J Bone Joint
Surg 58A:70, 1976.
Cole WH: The treatment of claw-foot, J Bone Joint Surg 22:895,
1940.
Colterjohn NR, Bednar DA: Procurement of bone graft from
the iliac crest, J Bone Joint Surg 79A:756, 1997.
Connolly J, Guse R, Lippiello L, et al: Development of an osteogenic bone-marrow preparation, J Bone Joint Surg 71A:684,
1989.
Cornell CN: Initial clinical experience with use of Collagraft as
a bone graft substitute, Tech Orthop 7:55, 1992.
Coventry MB, Tapper EM: Pelvic instability: a consequence of
removing iliac bone for grafting, J Bone Joint Surg 54A:83,
1972.
Crenshaw AG, Hargens AR, Gershuni DH, et al: Wide tourniquet cuffs more effective at lower in ation pressures, Acta
Orthop Scand 59:447, 1988.
Dirschl DR, Wilson FC: Topical antibiotic irrigation in the
prophylaxis of operative wound infections in orthopedic
surgery, Orthop Clin North Am 22:419, 1991.
Dobner JJ, Nitz AJ: Postmeniscectomy tourniquet palsy and functional sequelae, Am J Sports Med 10:211, 1982.
Doppelt SH, Tomford WW, Lucas AD, et al: Operational and
nancial aspects of a hospital bone bank, J Bone Joint Surg
63A:1472, 1981.
Enneking WF, Mindell ER: Observations on massive retrieved
human allografts, J Bone Joint Surg 73A:1123, 1991.
Estrera AS, King RP, Platt MR: Massive pulmonary embolism:
a complication of the technique of tourniquet ischemia, J
Trauma 22:60, 1982.
Fahmy NR, Patel DG: Hemostatic changes and postoperative
deep-vein thrombosis associated with the use of a pneumatic
tourniquet, J Bone Joint Surg 63A:461, 1981.
Flynn JM, Springeld DS, Mankin HJ: Osteoarticular allografts
to treat distal femoral osteonecrosis, Clin Orthop Relat Res
303:38, 1994.
Friedlaender GE: Current concepts review: bone-banking, J Bone
Joint Surg 64A:307, 1982.
Friedlaender GE: Current concepts review: bone grafts: the basic
science rationale for clinical applications, J Bone Joint Surg
69A:786, 1987.
Friedlaender GE, Tomford W, Galloway M, et al: Tissue transplantation. In Starzl TE, Shapiro R, Simmons RL, eds: Atlas
of organ transplantation, New York, 1992, Raven Press.

125

Froimson AI, Cummings AG Jr: Iliac hernia following hip


arthrodesis, Clin Orthop Relat Res 80:89, 1971.
Garn SR, ed: Complications of spine surgery, Baltimore, 1989,
Williams & Wilkins.
Gore DR, Gardner GM, Sepic SB, et al: Function following
partial bulectomy, Clin Orthop Relat Res 220:206, 1987.
Greene TL, Louis DS: Compartment syndrome of the arma
complication of the pneumatic tourniquet, J Bone Joint Surg
65A:270, 1983.
Greenwald AS, Boden SD, Goldberg VM, et al: Bone-graft substitutes: facts, ctions, and applications, J Bone Joint Surg
83A:98, 2001.
Hankin FM, Papadopoulos S: A sterile pneumatic tourniquet for
surgical procedures about the elbow, Orthop Rev 17:1240,
1988.
Heiple KG, Goldberg VM, Powell AE, et al: Biology of cancellous bone grafts, Orthop Clin North Am 18:179, 1987.
Henderson MS: Nonunion in fractures: the massive bone graft,
JAMA 81:463, 1923.
Henry MO: Homografts in orthopedic surgery, J Bone Joint Surg
30A:70, 1948.
Hirota K, Hashimoto H, Kabara S, et al: The relationship
between pneumatic tourniquet time and the amount of pulmonary emboli in patients undergoing knee arthroscopic
surgery, Anesth Analg 93:776, 2001.
Horowitz MC, Friedlaender GE: Immunologic aspects of bone
transplantation: a rationale for future studies, Orthop Clin North
Am 18:227, 1987.
Inclan A: The use of preserved bone graft in orthopedic surgery,
J Bone Joint Surg 24:81, 1942.
Jones AAM, Dougherty PJ, Sharkey NA, et al: Iliac crest bone
graft: saw versus osteotome, Spine 18:2048, 1993.
Khuri S, Uhl RL, Martino J, et al: Clinical application of the
forearm tourniquet, J Hand Surg 19A:861, 1994.
Kirn TF: Developments like major resection bone allografts foster
progress in tissue-banking technology, JAMA 258:305, 1987.
Klenerman L, Biswas M, Hulands GH, et al: Systemic and local
effects of the application of a tourniquet, J Bone Joint Surg
62B:385, 1980.
Krackow KA: A maneuver for improved positioning of a tourniquet in the obese patient, Clin Orthop Relat Res 168:80,
1982.
Krackow KA, Cohn BT: A new technique for passing tendon
through bone: brief note, J Bone Joint Surg 69A:922, 1987.
Krackow KA, Thomas SC, Jones LC: Ligament-tendon xation:
analysis of a new stitch and comparison with standard techniques, Orthopedics 11:909, 1988.
Kutty S, McElwain JP: Padding under tourniquets in tourniquet
controlled surgery: Bruners ten rules revisited, Injury 33:75,
2002.
Lane JM, Sandhu HS: Current approaches to experimental bone
grafting, Orthop Clin North Am 18:213, 1987.
Lawrence TK, Garn SR, Booth RE: Harvesting autogenous
iliac bone grafts: a review of complications and techniques,
Spine 14:1324, 1989.
Lotem M, Maor P, Haimoff H, et al: Lumbar hernia at an iliac
bone graft donor site: a case report, Clin Orthop Relat Res
80:130, 1971.
Lundborg G, Rydevik B: The tourniquet in extremity surgery:
how can complications be avoided? Acta Orthop Scand 54:669,
1983.
Meeder PJ, Eggers C: Techniques for obtaining autogenous bone
graft, Injury 1(suppl):5, 1994.
Meyer DC, Jacob HAC, Pistoia W, et al: The use of acrylic
bone cement for suture anchoring, Clin Orthop Relat Res
410:295, 2003.

126

Part I General Principles

Michelson JD, Perry M: Clinical safety and efcacy of calf tourniquets, Foot Ankle 17:573, 1996.
Morbidity and Mortality Weekly Report: Transmission of HIV
through bone transplantation: case report and public health
recommendations, JAMA 260:2487, 1988.
Muscolo DL, Caletti E, Schajowicz F, et al: Tissue-typing in
human massive allografts of frozen bone, J Bone Joint Surg
69A:583, 1987.
Nusbickel FR, Dell PC, McAndrew MP, et al: Vascularized
autografts for reconstruction of skeletal defects following lower
extremity trauma: a review, Clin Orthop Relat Res 243:65,
1989.
Parikh SN: Bone graft substitutes in modern orthopedics,
Orthopedics 25:1301, 2002.
Patterson S, Klenerman L, Biswas M, et al: The effect of pneumatic tourniquets on skeletal muscle physiology, Acta Orthop
Scand 52:171, 1981.
Pedowitz RA, Gershuni DH, Botte MJ, et al: The use of lower
tourniquet in ation pressures in extremity surgery facilitated
by curved and wide tourniquets and integrated cuff in ation
system, Clin Orthop Relat Res 287:237, 1993.
Pelker RR, Friedlaender GE: Biomechanical aspects of
bone autografts and allografts, Orthop Clin North Am 18:235,
1987.
Reid HS, Camp RA, Jacob WH: Tourniquet hemostasis: a clinical study, Clin Orthop Relat Res 177:230, 1983.
Reid RL: Hernia through an iliac bone-graft donor site: a case
report, J Bone Joint Surg 50A:757, 1968.
Rorabeck CH: Tourniquet-induced nerve ischemia: an experimental investigation, J Trauma 20:280, 1980.
Rorabeck CH, Kennedy JC: Tourniquet-induced nerve ischemia
complicating knee ligament surgery, Am J Sports Med 8:98,
1980.
Sapega AA, Heppenstall RB, Chance B, et al: Optimizing tourniquet application and release times in extremity surgery: a
biochemical and ultrastructural study, J Bone Joint Surg 67A:303,
1985.
Saunders KC, Louis DL, Weingarden SI, et al: Effect of tourniquet time on postoperative quadriceps function, Clin Orthop
Relat Res 143:194, 1979.
Scarborough NL: Allograft bones and soft tissues: current procedures for banking allograft human bone, Orthopedics 15:1161,
1992.
Shaw JA, Murray DG: The relationship between tourniquet pressure and underlying soft-tissue pressure in the thigh, J Bone
Joint Surg 64A:1148, 1982.
Simon MA, Mass DP, Zarins CK, et al: The effect of a thigh
tourniquet on the incidence of deep venous thrombosis after
operations on the fore part of the foot, J Bone Joint Surg
64A:188, 1982.
Simonis RB, Shirall HR, Mayou B: Free vascularized bular
grafts for congenital pseudoarthrosis of the tibia, J Bone Joint
Surg 73B:211, 1991.
Stevenson S: The immune response to osteochondral allografts
in dogs, J Bone Joint Surg 69A:573, 1987.
Tingart MJ, Apreleva M, Lehtinen J, et al: Anchor design and
bone mineral density affect the pull-out strength of suture
anchors in rotator cuff repair: which anchors are best to use in
patients with low bone quality? Am J Sports Med 32:1466,
2004.
Tomford WW, Mankin JH, Friedlaender GE, et al: Methods of
banking bone and cartilage for allograft transplantation, Orthop
Clin North Am 18:241, 1987.
Tomford WW, Starkweather RJ, Goldman MH: A study of the
clinical incidence of infection in the use of banked allograft
bone, J Bone Joint Surg 63A:244, 1981.

Wientroub S, Goodwin D, Khermosh O, et al: The clinical use


of autologous marrow to improve osteogenic potential of
bone grafts in pediatric orthopaedics, J Pediatr Orthop 9:186,
1989.
Wolfe SA, Kawamoto HK: Taking the iliac-bone graft: a new
technique, J Bone Joint Surg 60A:411, 1978.
Younger ASE, McEwen JA, Inkpen K: Wide contoured cuffs and
automated limb occlusion measurement allow lower tourniquet
pressures, Clin Orthop Relat Res 428:286, 2004.
Surgical Approaches
General
Banks SW, Laufman H: An atlas of surgical exposures of the extremities, Philadelphia, 1953, WB Saunders.
Borges AF: Zigzag incisions for improved posture and scarring,
Clin Orthop Relat Res 145:202, 1979.
Henry AK: Extensile exposure, 2nd ed, Edinburgh, 1966, E & S
Livingstone.
Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the
anatomic approach, Philadelphia, 2003, Lippincott Williams &
Wilkins.
Kocher T: Textbook of operative surgery, 3rd ed, London, 1911,
Adam & Charles Black (Translated by HJ Stiles, CB Paul).
Kocher T: Chirurgische operationslehre, 5th ed, Edinburgh, 1911,
Adam & Charles Black ( Jena, Gustav Fischer; Translated by
HJ Stiles).
Stookey B: Surgical and mechanical treatment of peripheral nerves,
Philadelphia, 1922, WB Saunders.
Thompson JE: Anatomical methods of approach in operations
on the long bones of the extremities, Ann Surg 68:309,
1918.
Calcaneus
Kocher T: Textbook of operative surgery, 3rd ed, London,
1911, Adam & Charles Black (Translated by HJ Stiles, CB
Paul).
Tarsus and Ankle
Broomhead R: Discussion on fractures in the region of the ankle
joint, Proc R Soc Med 25:1082, 1932.
Colonna PC, Ralston EL: Operative approaches to the ankle
joint, Am J Surg 82:44, 1951.
Gatellier J, Chastang P: Access to fractured malleolus with piece
chipped off at back, J Chir 24:513, 1924.
Koenig F, Schaefer P: Osteoplastic surgical exposure of the ankle
joint. In Forty- rst report of progress in orthopedic surgery,
p 17. (Abstracted from Z Chir 215:196, 1929.)
Nicola T: Atlas of surgical approaches to bones and joints, New York,
1945, Macmillan.
Ollier P: Traite des resections, Paris, 1892. (Quoted in Steindler A:
A textbook of operative orthopedics, New York, 1925, D
Appleton.)
Tibia and Fibula
Banks SW, Laufman H: An atlas of surgical exposures of the extremities, Philadelphia, 1953, WB Saunders.
Harmon PH: A simplied surgical approach to the posterior tibia
for bone-grafting and bular transference, J Bone Joint Surg
27:496, 1945.
Henry AK: Exposures of long bones and other surgical methods, Bristol,
England, 1927, John Wright & Sons.
Phemister DB: Treatment of ununited fractures by onlay bone
grafts without screw or tie xation and without breaking down
of the brous union, J Bone Joint Surg 29:946, 1947.
Tochigi Y, Amendola A, Muir D, et al: Surgical approach for
centrolateral talar osteochondral lesions with an anterolateral
osteotomy, Foot Ankle Int 23:1038, 2002.

Chapter 1 Surgical Techniques and Approaches

Knee
Abbott LC, Carpenter WF: Surgical approaches to the knee joint,
J Bone Joint Surg 27:277, 1945.
Brackett EG, Osgood RB: The popliteal incision for the removal
of joint mice in the posterior capsule of the knee-joint: a
report of cases, Boston Med Surg J 165:975, 1911.
Brown CW, Odom JA Jr, Messner DG, et al: A simplied operative approach for the lateral meniscus, J Sports Med 3:265,
1975.
Bruser DM: A direct lateral approach to the lateral compartment
of the knee joint, J Bone Joint Surg 42B:348, 1960.
Cave EF: Combined anterior-posterior approach to the knee
joint, J Bone Joint Surg 17:427, 1935.
Chambers GH: The prepatellar nerve: a cause of suboptimal
results in knee arthrotomy, Clin Orthop Relat Res 82:157,
1972.
Charnley J: Horizontal approach to the medial semilunar cartilage, J Bone Joint Surg 30B:659, 1948.
Erkes F: Weitere Erfahrungen mit physiologischer Schnitt
fhrung zur erffnung des Kniegelenks, Bruns Beitr zur Klin
Chir 147:221, 1929.
Fernandez DL: Anterior approach to the knee with osteotomy of
the tibial tubercle for bicondylar tibial fractures, J Bone Joint
Surg 70A:208, 1988.
Gossling HR, Peterson CA: A new surgical approach in the
treatment of depressed lateral condylar fractures of the tibia,
Clin Orthop Relat Res 140:96, 1979.
Henderson MS: Posterolateral incision for the removal of loose
bodies from the posterior compartment of the knee joint, Surg
Gynecol Obstet 33:698, 1921.
Hofmann AA, Plaster RL, Murdock LE: Subvastus (Southern)
approach for primary total knee arthroplasty, Clin Orthop Relat
Res 269:70, 1991.
Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the
anatomic approach, Philadelphia, 2003, Lippincott Williams &
Wilkins.
Insall JN: A midline approach to the knee, J Bone Joint Surg
53A:1584, 1971.
Jones R: Disabilities of the knee-joint, Br Med J 2:169, 1916.
Kaplan EB: Surgical approach to the lateral (peroneal) side of the
knee joint, Surg Gynecol Obstet 104:346, 1957.
Keblish PA: The lateral approach to the valgus knee: surgical
technique and analysis of 53 cases with over two-year followup evaluation, Clin Orthop Relat Res 271:52, 1991.
Kocher T: Textbook of operative surgery, 3rd ed, London, 1911,
Adam & Charles Black (Translated by HJ Stiles, CB Paul).
Kummel BM, Zazanis GA: Preservation of intrapatellar branch
of saphenous nerve during knee surgery, Orthop Rev 3:43,
1974.
Langenbeck B von: ber die Schussverletzungen des Huftgelenks,
Arch Klin Chir 16:263, 1874.
McConnell BE: A dynamic transpatellar approach to the knee,
South Med J 69:557, 1976.
McConnell JC: Paper presented at the Thirteenth Triennial
Meeting of the Willis C Campbell Club, Memphis, Tenn, Oct
1985.
Minkoff J, Jaffe L, Menendez L: Limited posterolateral surgical
approach to the knee for excision of osteoid osteoma, Clin
Orthop Relat Res 223:237, 1987.
Perry CR, Evans LG, Fogarty J, et al: A new surgical approach
to fractures of the lateral tibial plateau, J Bone Joint Surg
66A:1236, 1984.
Pogrund H: A practical approach for lateral meniscectomy,
J Trauma 16:365, 1976.
Putti V: Arthroplasty of the knee joint, J Orthop Surg 2:530,
1920.

127

Wilson PD: Posterior capsularplasty in certain exion contractures of the knee, J Bone Joint Surg 11:40, 1929.
Femur
Bosworth DM: Posterior approach to the femur, J Bone Joint Surg
26:687, 1944.
Checroun AJ, Mekhail AO, Ebraheim NA, et al: Extensile medial
approach to the femur, J Orthop Trauma 10:481, 1996.
Henry AK: Exposure of the humerus and femoral shaft, Br J Surg
12:84, 19241925.
Thompson JE: Anatomical methods of approach in operations on
the long bones of the extremities, Ann Surg 68:309, 1918.
Hip
Abbott LC: Surgical approaches to the joints. In Cole WH, ed:
Operative technic in specialty surgery, New York, 1949,
Appleton-Century-Crofts.
Brackett E: A study of the different approaches to the hip joint,
with special reference to the operations for curved trochanteric
osteotomy and for arthrodesis, Boston Med Surg J 166:235,
1912.
Ferguson AB Jr: Primary open reduction of congenital dislocation of the hip using a median adductor approach, J Bone Joint
Surg 55A:671, 1973.
Frndak PA, Mallory TH, Lombardi AV: Translateral surgical
approach to the hip: the abductor muscle split, Clin Orthop
Relat Res 295:135, 1993.
Gibson A: Vitallium cup arthroplasty of the hip joint, J Bone Joint
Surg 31A:861, 1949.
Gibson A: Posterior exposure of the hip joint, J Bone Joint Surg
32B:183, 1950.
Gibson A: The posterolateral approach to the hip joint, AAOS
Instr Course Lect 10:175, 1953.
Hardinge K: The direct lateral approach to the hip, J Bone Joint
Surg 64B:17, 1982.
Harris WH: A new lateral approach to the hip joint, J Bone Joint
Surg 49A:891, 1967.
Harris WH: Extensive exposure of the hip joint, Clin Orthop
Relat Res 91:58, 1973.
Henry AK: Exposures of long bones and other surgical methods, Bristol,
England, 1927, John Wright & Sons.
Hoppenfeld S, deBoer P: Surgical exposures in orthopaedics: the
anatomic approach, Philadelphia, 2003, Lippincott Williams &
Wilkins.
Iyer KM: A new posterior approach to the hip joint, Injury 13:76,
1981.
Kaplan EB: The blood vessels of the gluteal region, Bull Hosp Jt
Dis 7:165, 1946.
Kocher T: Textbook of operative surgery, 3rd ed, London, 1911,
Adam & Charles Black (Translated by HJ Stiles, CB Paul).
Langenbeck B von: ber die Schussverletzungen des Huftgelenks,
Arch Klin Chir 16:263, 1874.
Ludloff K: Zur blutigen Einrenkung der angeborenen
Huftluxation, Z Orthop Chir 22:272, 1908.
Mallon WJ, Fitch RD: The medial approach to the hip revisited,
Orthopedics 16:39, 1993.
Marcy GH, Fletcher RS: Modication of the posterolateral
approach to the hip for insertion of femoral-head prosthesis, J
Bone Joint Surg 36A:142, 1954.
McFarland B, Osborne G: Approach to the hip: a suggested
improvement on Kochers method, J Bone Joint Surg 36B:364,
1954.
McLauchlan J: The Stracathro approach to the hip, J Bone Joint
Surg 66B:30, 1984.
Moore AT: The self-locking metal hip prosthesis, J Bone Joint Surg
39A:811, 1957.

128

Part I General Principles

Moore AT: The Moore self-locking Vitallium prosthesis in fresh


femoral neck fractures: a new low posterior approach
(the southern exposure), AAOS Instr Course Lect 16:309,
1959.
Osborne RP: The approach to the hip-joint: a critical review and
a suggested new route, Br J Surg 18:49, 19301931.
Schaubel HJ: Modication of the anterior iliofemoral approach
to the hip, Int Surg 65:347, 1980.
Smith-Petersen MN: A new supra-articular subperiosteal approach
to the hip joint, Am J Orthop Surg 15:592, 1917.
Smith-Petersen MN: Approach to and exposure of the hip joint
for mold arthroplasty, J Bone Joint Surg 31A:40, 1949.
Somerville EW: Open reduction in congenital dislocation of the
hip, J Bone Joint Surg 35B:363, 1953.
Testa NN, Mazur KU: Heterotopic ossication after direct lateral
approach and transtrochanteric approach to the hip, Orthop Rev
17:965, 1988.
Watson-Jones R: Fractures of the neck of the femur, Br J Surg
23:787, 19351936.
Acetabulum and Pelvis
Carnesale PG: Personal communication, 1977.
Charnley J, Ferriera A, De SO: Transplantation of the greater
trochanter in arthroplasty of the hip, J Bone Joint Surg 46B:191,
1964.
Krackow KA, Steinmann H, Cohn BT, et al: Clinical experience
with the triradiate exposure of the hip for difcult total hip
arthroplasty, J Arthroplasty 3:267, 1988.
Letournel E: Les fractures du cotyle: tude dune serie de 75 cas,
J Chir 82:47, 1961.
Letournel E, Judet R: Fractures of the acetabulum, New York, 1981,
Springer-Verlag.
Matta JM: Anterior exposure with the ilioinguinal approach. In
Mears DC, Rubash HE, eds: Pelvic and acetabular fractures,
Thorofare, NJ, 1986, SLACK.
Mears DC, Rubash HE: Extensile exposure of the pelvis, Contemp
Orthop 6:21, 1983.
Mears DC, Rubash HE, eds: Pelvic and acetabular fractures,
Thorofare, NJ, 1986, SLACK.
Reinert CM, Bosse MJ, Poka A, et al: A modied extensile
exposure for the treatment of complex or malunited acetabular
fractures, J Bone Joint Surg 70A:329, 1988.
Ischium
Radley TJ, Liebig CA, Brown JR: Resection of the body of the
pubic bone, the superior and inferior pubic rami, the inferior
ischial ramus, and the ischial tuberosity, J Bone Joint Surg
36A:855, 1954.
Symphysis Pubis
Pfannenstiel HJ: ber die Vorteile des suprasymphysren
Fascienquerschnitt fr die gynaekologischen Koeliotomien,
Samml Klin Vortr Gynaekol (Leipzig) 268:1735, 1900.
Sacroiliac Joint
Avila L Jr: Primary pyogenic infection of the sacro-iliac articulation: a new approach to the joint, J Bone Joint Surg 23:922,
1941.
Mears DC, Rubash HE, eds: Pelvic and acetabular fractures,
Thorofare, NJ, 1986, SLACK.
Acromioclavicular Joint
Roberts SM: Acromioclavicular dislocation, Am J Surg 23:322,
1934.
Shoulder
Abbott LC, Lucas DB: The tripartite deltoid and its surgical signicance in exposure of the scapulohumeral joint, Ann Surg
136:392, 1952.

Abbott LC, Lucas DB: The function of the clavicle: its surgical
signicance, Ann Surg 140:583, 1954.
Abbott LC, Saunders JBDM, Hagey H, et al: Surgical approaches
to the shoulder joint, J Bone Joint Surg 31A:235, 1949.
Armstrong JR: Excision of the acromion in treatment of the
supraspinatus syndrome: report of ninety-ve excisions, J Bone
Joint Surg 31B:436, 1949.
Bennett GE: Shoulder and elbow lesions of professional baseball
pitcher, JAMA 117:510, 1941.
Brodsky JW, Tullos HS, Gartsman GM: Simplied posterior
approach to the shoulder joint: a technical note, J Bone Joint
Surg 71A:407, 1989.
Codman EA: Obscure lesions of the shoulder: rupture of the
supraspinatus tendon, Boston Med Surg J 196:381, 1927.
Cubbins WR, Callahan JJ, Scuderi CS: The reduction of old or
irreducible dislocations of the shoulder joint, Surg Gynecol
Obstet 58:129, 1934.
Darrach W: Surgical approaches for surgery of the extremities,
Am J Surg 67:237, 1945.
Harmon PH: A posterior approach for arthrodesis and other
operations on the shoulder, Surg Gynecol Obstet 81:266,
1945.
Henry AK: Exposures of long bones and other surgical methods, Bristol,
England, 1927, John Wright & Sons.
Kocher T: Textbook of operative surgery, 3rd ed, London, 1911,
Adam & Charles Black (Translated by HJ Stiles, CB Paul).
Kuz JE, Pierce TD, Braunohler WB: Coronal transacromial osteotomy surgical approach for shoulder arthroplasty, Orthopedics
21:155, 1998.
McLaughlin HL: Lesions of the musculotendinous cuff of the
shoulder: I. the exposure and treatment of tears with retraction, J Bone Joint Surg 26:31, 1944.
McWhorter GL: Fracture of the greater tuberosity of the humerus
with displacement: report of two operated cases with authors
technic of shoulder incision, Surg Clin North Am 5:1005,
1925.
McWhorter GL: Old posterior dislocation of the shoulder with
complete disability: reduction by the authors posterior shoulder incision; technic of applying shoulder spica, Surg Clin North
Am 12:1239, 1932.
Rowe CR, Yee LBK: A posterior approach to the shoulder joint,
J Bone Joint Surg 26:580, 1944.
Thompson JE: Anatomical methods of approach in operations on
the long bones of the extremities, Ann Surg 68:309, 1918.
Humerus
Berger RA, Buckwalter JA: A posterior surgical approach to the
proximal part of the humerus, J Bone Joint Surg 71A:407,
1989.
Henry AK: Exposure of the humerus and femoral shaft, Br J Surg
12:84, 19241925.
King A, Johnston GH: A modication of Henrys anterior
approach to the humerus, J Shoulder Elbow Surg 7:210, 1998.
Moran MC: Modied lateral approach to the distal humerus for
internal xation, Clin Orthop Relat Res 340:190, 1997.
Thompson JE: Anatomical methods of approach in operations on
the long bones of the extremities, Ann Surg 68:309, 1918.
Elbow
Bain GI, Mehta JA: Anatomy of the elbow joint and surgical
approaches. In Baker CL Jr, Plancher KD, eds: Operative strategies of the elbow, New York, 2001, Springer-Verlag.
Bryan RS, Morrey BF: Extensive posterior exposure of the
elbow: a triceps-sparing approach, Clin Orthop Relat Res
166:188, 1982.
Cadenat FM: Les vois de penetration des membres, Paris, Membre
Superieur, 1932.

Chapter 1 Surgical Techniques and Approaches

Campbell WC: Incision for exposure of the elbow joint, Am J


Surg 15:65, 1932.
Ewald FC, Scheinberg RD, Poss R, et al: Capitellocondylar total
elbow arthroplasty: two to ve year followup in rheumatoid
arthritis, J Bone Joint Surg 62A: 1239, 1980.
Hotchkiss R: Compass universal hinge: surgical technique, Memphis,
Tenn, Smith and Nephew, 1998.
Kaplan EB: Surgical approach to the proximal end of the radius
and its use in fractures of the head and neck of the radius,
J Bone Joint Surg 23:86, 1941.
Key JA, Conwell HE: The management of fractures, dislocations, and
sprains, 2nd ed. St Louis, Mosby, 1937.
Kocher T: Textbook of operative surgery, 3rd ed, London, 1911,
Adam & Charles Black (Translated by HJ Stiles, CB Paul).
MacAusland WR: Ankylosis of the elbow: with report of four
cases treated by arthroplasty. JAMA 64:312, 1915.
Mehta JA, Bain GI: Surgical approaches to the elbow, Hand Clin
20;375, 2004.
Molesworth WHL: Operation for complete exposure of the
elbow joint, Br J Surg 18:303, 1930.
Morrey BF, Bryan RS, Dobyns JH, et al: Total elbow arthroplasty: a ve-year experience at the Mayo Clinic, J Bone Joint
Surg 63A:1050, 1981.
Mller ME, Allgwer M, Schneider R, et al: Manual of internal
xation: techniques recommended by the AO-ASIF group, 3rd ed,
Berlin, Springer-Verlag, 1991.
Patterson SO, Bain GI, Mehta JA: Surgical approaches to the
elbow, Clin Orthop Relat Res 370:19, 2000.

129

Wadsworth TG: A modied posterolateral approach to the


elbow and proximal radioulnar joints, Clin Orthop Relat Res
144:151, 1979.
Wilkinson JM, Stanley D: Posterior surgical approaches to the
elbow: a comparative anatomic study, J Shoulder Elbow Surg
10:380, 2001.
Radius
Henry AK: Exposures of long bones and other surgical methods, Bristol,
England, 1927, John Wright & Sons.
Strachan JCH, Ellis BW: Vulnerability of the posterior interosseous nerve during radial head resection, J Bone Joint Surg
53B:320, 1971.
Thompson JE: Anatomical methods of approach in operations on
the long bones of the extremities, Ann Surg 68:309, 1918.
Ulna
Boyd HB: Surgical exposure of the ulna and proximal third of
the radius through one incision, Surg Gynecol Obstet 71:86,
1940.
Gordon ML: Monteggia fracture: a combined surgical approach
employing a single lateral incision, Clin Orthop Relat Res 50:87,
1967.
Wrist
Smith-Petersen MN: A new approach to the wrist joint, J Bone
Joint Surg 22:122, 1940.

Magnetic Resonance
Imaging in Orthopaedics
Chapter 2

Dexter H. Witte

Types of magnetic resonance


imaging scans ...................... 130
Contraindications .................... 132
Foot and ankle ........................
Tendon injuries ...........................
Ligament injuries ........................
Other disorders of the foot and
ankle .......................................

132
132
132

Knee ...........................................
Pathological conditions of the
menisci ....................................
Cruciate ligament injury ............
Other knee problems .................

134

132

136
138
138

Hip .............................................
Osteonecrosis ..............................
Transient osteoporosis ................
Trauma .......................................

140
142
142
143

Spine ..........................................
Intervertebral disc disease ..........
Postoperative back pain ..............
Spinal tumors .............................
Spinal trauma .............................

144
144
144
147
147

Shoulder .................................... 147


Pathological conditions of the
rotator cuff .............................. 147
Impingement syndromes ............ 148

Aside from routine radiography, no imaging method has as


great an effect on the current practice of orthopaedics as
MRI. MRI provides unsurpassed soft-tissue contrast and
multiplanar capability with spatial resolution that approaches
that of CT. Consequently, MRI has superseded older
imaging methods, such as myelography, arthrography, and
angiography. In some areas, such as the knee and shoulder,
MRI has become a powerful diagnostic tool, helping the
surgeon to evaluate structures that are otherwise invisible
to noninvasive techniques. As an evolving technology, the
ultimate role of MRI in orthopaedics is still to be determined. Continued improvements in hardware and software
undoubtedly will expand the role of MRI in orthopaedics
and in other elds of medicine.
MRI is unrelated to any of the older imaging techniques. MRI images are created by placing the patient in
a strong magnetic eld (approximately 30,000 stronger
than the earths magnetic eld). The magnetic force affects
the nuclei within the eld, specically the nuclei of elements with odd numbers of protons or neutrons. The most
abundant element satisfying this criterion is hydrogen,
which is plentiful in water and fat. These nuclei, which are
essentially protons, possess a quantum spin. When the
patients tissues are subjected to this strong magnetic eld,

Pathological conditions of the


labrum ..................................... 148
Other causes of shoulder
pain ......................................... 149
Wrist and elbow ...................... 149
Carpal ligament disruptions ....... 150
Other pathological conditions
of the hand and wrist ............. 150
Elbow ........................................ 150
Tumor imaging ....................... 151
Summary .................................. 155

protons align themselves with respect to the eld. Because


all imaging is performed within this constant magnetic
force, this becomes the steady state, or equilibrium. In this
steady state, a radiofrequency pulse is applied, which excites
the magnetized protons in the eld and perturbs the steady
state. After application of this pulse, a receiver coil or
antenna listens for an emitted radiofrequency signal that is
generated as these excited protons relax or return to equilibrium. This signal, with the help of localizing gradient
elds and Fourier transformation, creates the MRI
image.

TYPES OF MAGNETIC RESONANCE


IMAGING SCANS
Although all studies involve magnetization and radiofrequency signals, the method and timing of excitation and
acquisition of the signal can be varied to affect the contrast
of the various tissues in the volume. Most musculoskeletal
MRI examinations use the spin-echo technique, which
produces T1-weighted, proton (spin) density, and T2weighted images. T1 and T2 are tissue-specic characteristics. These values reect measurements of the rate of

130

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Chapter 2 Magnetic Resonance Imaging in Orthopaedics

relaxation to the steady state. By varying the timing of the


application of radiofrequency pulses (repetition time [TR])
and the timing of acquisition of the returning signal (echo
time [TE]), an imaging sequence can accentuate T1 or T2
characteristics. A fairly constant rule is that fat has a high
signal (bright) on T1-weighted images, and uid has a high
signal on T2-weighted images. Structures with little water
or fat, such as cortical bone, tendons, and ligaments, remain
dark in all types of sequences. Faster imaging methods are
becoming available. Fast spin-echo technique can reduce
the length of T2-weighted sequences by two thirds or
more. Some fast spin-echo sequences introduce blurring
artifact, which can obscure tiny abnormalities, such as
meniscal tears. In addition, fat signal in fast spin-echo
images remains fairly intense, a problem that can be eliminated by chemical shift fat-suppression techniques (Fig. 21). Fat suppression also can be achieved by using a short-tau
inversion recovery (STIR) sequence. These fat-suppression
techniques can be useful in the detection of edema in bone
marrow and soft tissue and play an important role in the
imaging of trauma and neoplasms. Another fast imaging
method, gradient-echo technique, is used selectively for
cartilage imaging (e.g., for the glenoid labrum). Most MRI
studies are composed of numerous imaging sequences or
series, tailored to detect and dene a certain pathological
process. Because the imaging planes (axial, sagittal, coronal,
oblique) and the sequence type (T1, T2, gradient-echo) are
chosen at the outset, advanced understanding of the clinical
problem is required to perform high-quality imaging.
A wide variety of MRI systems are commercially available. Scanners can be grouped roughly by eld strength.
High-eld scanners are considered to have a eld strength
of 1 to 3 tesla (T). Low-eld scanners operate at eld

131

strengths of 0.3 T or less. Currently, there is much debate


regarding the relative performance of high-eld and loweld systems. Each type of system has distinct advantages.
High-eld scanners generate higher signal-to-noise images,
allowing shorter scanning times, thinner scan slices, and
smaller elds of view. Chemical shift fat suppression is not
available in low-eld scanners. Low-eld scanners usually
are of an open conguration that allows greater patient
comfort and ease in imaging off-axis structures, such as
elbows and wrists. Low-eld systems also are less expensive
to purchase and operate. The quality and accuracy of loweld systems compared with high-eld scanners are debatable. Relatively few comparative studies have been
published; however, some studies suggest that the difference in the diagnostic accuracy of high-eld and low-eld
scanners in the evaluation of menisci and ligaments of the
knee is insignicant. Whether this accuracy can be extrapolated to other musculoskeletal examinations is unknown.
High-eld systems with an open conguration are on
the horizon, and they combine many of the advantages of
current high-eld and low-eld scanners.
An image can be acquired in the main coil (the hollow
tube in which the patient lies during the study). This may
be satisfactory when studying the chest, abdomen, or pelvis,
where a large area is to be evaluated. In the musculoskeletal
system, the hips, thighs, or legs often may be examined
this way. For evaluation of smaller articular structures, such
as the menisci of the knee or the rotator cuff, specialized
surface coils are needed. Several types of surface coils are
available, including coils tailored for specic body parts,
such as the spine, shoulder, wrist, and temporomandibular
joints, and versatile exible coils and a circumferential long
bone coil. These coils serve as antennae placed close to the

B
Fig. 2-1 Chemical shift fat-suppression technique. A, Axial fast spin-echo, T2-weighted image
of large soft-tissue mass in calf. Hyperintense fat blends with anterior and posterior margins
of lesion. B, Addition of fat suppression allows for better delineation of tumor margins.

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132

Part I General Principles

imaging volume, markedly improving signal and resolution. The drawback is that only limited areas can be studied.
Larger coils have been developed with phased-array technology, providing the improved signal that is seen in
smaller coils with an expanded coverage area. These
phased-array coils are commercially available for the knee,
shoulder, and torso and are compatible with most new
MRI systems. Optimal coil selection is mandatory for
high-quality imaging of joints or small parts.

CONTRAINDICATIONS
Some patients are not candidates for MRI. Absolute contraindications to MRI include intracerebral aneurysm clips,
cardiac pacemakers, automatic debrillators, biostimulators, certain implanted infusion devices, internal hearing
aids, and metallic orbital foreign bodies. Cardiac valve
prostheses can be scanned safely. Relative contraindications
include rst-trimester pregnancy, middle ear prostheses,
and penile prostheses. Generally, internal orthopaedic
hardware and orthopaedic prostheses are safe to scan,
although ferrous metals can create local artifact that can
obscure adjacent tissues. Metal prostheses also may become
warm during the examination, although this is rarely
noticed by the patient and almost never requires termination of the study. Patients with metal external xation
devices should not be scanned. If there is a question regarding MRI compatibility of an implantable device (e.g., a
pain stimulator or infusion pump), the manufacturer should
be consulted.

FOOT AND ANKLE


The foot and ankle constitute a complex anatomical region
in the human body. The complexity of midfoot and hindfoot articulations and the variety of pathological conditions
in the tendon and ligament make evaluation difcult from
a clinical and imaging perspective. Most examinations of
the foot and ankle are performed to evaluate tendinopathy,
articular disorders, and osseous pathological conditions,
often after trauma. MRI can be useful when the examination is directed at solving a certain clinical problem, but it
should not be used as a screening study for nonspecic pain
because the yield is low. Given the small size of structures
to be examined, optimal imaging is achieved on a higheld strength (>1.0 T) magnet, and the use of a surface coil,
typically an extremity coil, is mandatory. Ideally, the clinical presentation allows the examination to be directed
toward the forefoot or the ankle or hindfoot. This arbitrary
division allows for a sufciently small eld of view (8 to
12 cm) to generate high-resolution images. Images can be
prescribed in orthogonal or oblique planes, with combinations of T1-weighted, T2-weighted, and fat-suppressed

Ch002-A03329.indd 132

sequences. The examination should be tailored to dene


the clinically suspected problem best.

Tendon Injuries
MRI excels in the evaluation of pathological conditions in
the numerous tendons around the ankle joint. Most commonly affected are the calcaneal and posterior tibial tendons.
In chronic tendinitis, the calcaneal tendon thickens and
becomes oval or circular in cross section. The enlarged
tendon maintains low signal on all sequences. When partially torn, the tendon shows focal or fusiform thickening
with interspersed areas of edema or hemorrhage that
brighten on T2-weighted series (Fig. 2-2). With complete
rupture, there is discontinuity of the tendon bers.
Similarly, abnormalities of the posterior tibial tendon can
be diagnosed condently with MRI. Increased uid in the
sheath of the tendon indicates tenosynovitis. Insufcient or
ruptured tendons can appear thickened, attenuated, or discontinuous (Fig. 2-3). Occasionally, similar abnormalities
are seen in the other exor tendons or peroneus tendons
(Fig. 2-4).

Ligament Injuries
Although ligamentous injuries around the ankle are
common, MRI has a limited role in their evaluation. The
medial and lateral stabilizing ligaments of the tibiotalar and
talocalcaneal joints and the distal tibiobular ligaments
usually can be seen with proper positioning of the foot.
The imaging status of ligaments around the ankle does not
change the treatment, however, in most patients. MRI has
been useful in evaluating the lateral recess of the ankle joint
in patients with chronic ankle sprains and impingement.
Regions of brosis frequently are seen in the lateral gutter,
especially when uid is present in the ankle joint.

Other Disorders of the Foot and Ankle


As elsewhere in the body, bone marrow disorders, osteonecrosis or fracture (Fig. 2-5), and osteochondral injuries
(Fig. 2-6) are well delineated. The excellent anatomical
information provided by MRI allows detection and denition of masses in the foot. One mass unique to the foot is
a Morton neuroma. Usually found in the third metatarsal
interspace distally, it is most often a clinical diagnosis based
on the presence of pain on the plantar surface of the foot
at this location. In contrast to most other tumors, this
lesion lacks increased signal on T2-weighted sequences.
Another condition for which MRI would seem especially well suited is infection in the foot of a diabetic
patient. Because of the excellent depiction of bone marrow,
osteomyelitis can be detected early, perhaps 7 to 10 days
before radiographic abnormalities are visible (Fig. 2-7).
The anatomical information provided by MRI can assist

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Chapter 2 Magnetic Resonance Imaging in Orthopaedics

133

B
Partial tear of calcaneal tendon. A, Sagittal T1-weighted image shows markedly
thickened calcaneal tendon containing areas of intermediate signal (arrow). B, Sagittal fat-suppressed, T2-weighted image exhibits uid within tendon substance, indicating partial tear
(arrow).
Fig. 2-2

Fig. 2-3 Posterior tibial tendon tear. A,


Axial T1-weighted image reveals swollen,
ill-dened region of intermediate signal
intensity, representing uid and abnormal
tendon (arrow). B, Axial fat-suppressed,
T2-weighted image shows thickened
tendon (arrow) surrounded by hyperintense uid.

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134

Part I General Principles

Fig. 2-4 Peroneus longus tendon rupture. A, Coronal T1-weighted image through midfoot
shows increased diameter of peroneus longus tendon (arrows). B, Coronal fat-suppressed, T2weighted image reveals uid signal within ruptured tendon (arrow).

in surgical planning by dening the extent of disease.


Certain fat-suppressed sequences are so sensitive that reactive marrow edema can be seen even before frank osteomyelitis. Although the sensitivity of MRI for osteomyelitis
approaches 100%, the reported specicity is less. Some
authors have suggested relying on T1-weighted marrow
replacement rather than T2-weighted signal abnormality

(edema) to increase specicity. As with scintigraphy, in


patients with neuropathic disease, the specicity is reduced
further; the current workup of osteomyelitis in a diabetic
foot often involves a combination of scintigraphy, MRI,
laboratory data, and physical examination. For the evaluation of surrounding soft-tissue infection, MRI is the
modality of choice. The addition of contrast-enhanced
sequences is helpful in dening nonenhanced uid collections or abscesses and devascularized or gangrenous tissue.
Although the diabetic foot can be a diagnostic challenge,
normal MRI marrow signal condently excludes
osteomyelitis.

KNEE

Fig. 2-5 Osteonecrosis of talus. Fat-suppressed proton


densityweighted image reveals focus of abnormal signal in
talar dome (arrow) after fracture of talar neck.

Ch002-A03329.indd 134

The knee is the most frequently studied region of the


appendicular skeleton. Standard extremity coils allow highresolution images of the commonly injured internal structures of the joint. The routine MRI examination of the
knee consists of spin-echo sequences obtained in sagittal,
coronal, and usually axial planes. Most examiners prefer to
evaluate the menisci on sagittal proton (spin) density
weighted images. The sagittal images are prescribed in a
plane parallel to the course of the anterior cruciate ligament (ACL), approximately 15 degrees internally rotated
to the true sagittal plane. Coronal images are useful in
evaluating medial and lateral supporting structures. The
patellofemoral joint is best seen in the axial plane.

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Chapter 2 Magnetic Resonance Imaging in Orthopaedics

135

Fig. 2-6 Osteochondritis dissecans of talus in college football player. A, Coronal T1-weighted
image shows osteochondral fragment in medial talar dome. Loss of fat signal suggests sclerosis
or brosis (arrow). B, Coronal fat-suppressed, T2-weighted image shows uid signal between
lesion and host bone (arrowheads), indicating unstable fragment. C, Coronal fat-suppressed,
spoiled gradient-echo technique reveals abnormal decreased signal (arrow) in overlying articular
cartilage, indicating defect conrmed by arthroscopy.

B
Fig. 2-7 Osteomyelitis in foot of diabetic patient. A, Lateral radiograph of hindfoot reveals no
abnormalities. B, Sagittal fat-suppressed, T2-weighted image shows increased signal in calcaneal
marrow (arrow), indicating osteomyelitis.

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Part I General Principles

Fig. 2-8 Meniscal tear. Sagittal proton densityweighted


image shows linear increased signal traversing posterior horn
of medial meniscus, indicating oblique tear (arrow).

Fig. 2-9 Meniscal tear. Sagittal proton densityweighted


image reveals small defect in free edge of body of lateral
meniscus, indicating radial tear (arrow).

Pathological Conditions of the Menisci


A large percentage of knee pain or disability is caused by
pathological conditions of the menisci. The menisci are
composed of brocartilage and appear as low-signal structures on all pulse sequences. Best evaluated in cross section
on sagittal images, the menisci appear as dark triangles in
the central portion of the joint and assume a bow tie
conguration at the periphery of the joint. Regions of
increased signal often can be seen within the normally dark
brocartilage of the menisci. These areas of increased signal
have been classied as grade 1 (globular), grade 2 (linear),
and grade 3. Grades 1 and 2 signal changes do not extend
to the articular surface of the meniscus and do not represent tears. These signal changes correspond to areas of
mucoid degeneration that are not visible arthroscopically.
Conversely, a grade 3 signal is a linear abnormality that
extends to the superior or inferior articular surface. A grade
3 signal abnormality represents a tear (Figs. 2-8 to 2-10).
Although it has been suggested that grade 1 and grade 2
changes progress to meniscal tears, follow-up examinations
have not shown this progression. Generally, signal abnormalities, which are seen on only one image, should not be
considered as tears unless there is associated anatomical
distortion of the meniscus. Meniscal tears should be dened
in regard to location (anterior horn, body, posterior horn,
free edge, periphery) and orientation (horizontal, vertical,
complex). Complications of tears, such as displaced frag-

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Fig. 2-10 Meniscal cyst. Coronal fat-suppressed, proton


densityweighted image of knee shows large hyperintense
meniscal cyst (thick arrow) adjacent to medial meniscus. An
associated tear is present in inferior articular surface of
meniscus (curved arrow).

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Chapter 2 Magnetic Resonance Imaging in Orthopaedics

137

Fig. 2-11 Bucket-handle tear of medial meniscus. Coronal (A) and axial (B) fat-suppressed,
proton densityweighted image shows centrally displaced portion of medial meniscus (arrows).

ments (bucket-handle tears, inferiorly displaced medial


fragment), should be suspected when the orthotopic portion
of the meniscus is small or truncated. Careful examination
of the joint, often in the coronal plane, reveals the displaced, hypointense meniscal fragment (Figs. 2-11 and

Fig. 2-12 Inferiorly displaced medial meniscal fragment. Fatsuppressed, proton densityweighted image shows portion of
medial meniscus displaced inferiorly and deep to medial collateral ligament (arrow).

Ch002-A03329.indd 137

2-12). The sensitivity and specicity of MRI in detecting


meniscal tears routinely exceed 90%.
Studies have shown that many factors affect the accuracy
of MRI with respect to meniscal evaluation, including the
experience of the radiologist in interpreting studies and the
orthopaedist in performing the correlating arthroscopy.
Many pitfalls in interpretation exist. When studying the
central portions of the menisci, the meniscofemoral ligaments and transverse meniscal ligament can create problems. Meniscocapsular separation often is difcult to detect
in the absence of a complete detachment and resulting freeoating meniscus. Elderly patients often exhibit greatly
increased intrameniscal signal that can be mistaken for a
tear. Specicity also is reduced in patients who have undergone previous meniscal repair, and some have argued that
arthrography still may be indicated in evaluating these
patients. Most examiners continue to rely on MRI in such
patients, however, using caution with menisci that have
greater degrees of surgical resection. The injection of
intraarticular gadolinium (MRI arthrography) can help
differentiate healed or repaired tears from reinjury.
Morphologic abnormalities of the menisci and adjacent
structures are clearly shown with MRI. The abnormally
thick or at discoid meniscus is seen more commonly on
the lateral side. Although the bow tie conguration of
the lateral meniscus in the sagittal plane on more than
three slices indicates a discoid meniscus, the abnormal cross
section usually is quite apparent on the coronal images (Fig.
2-13). Meniscal cysts, which usually are associated with
and adjacent to meniscal tears, frequently can be easily seen
as discrete collections marked by uid signal intensity that
are located medially or laterally (see Fig. 2-10).

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138

Part I General Principles

Fig. 2-13 Discoid meniscus in 3-year-old boy. A, Sagittal proton densityweighted image
reveals abnormally thick lateral meniscus (arrow). B, Coronal fat-suppressed, proton density
weighted image shows extension of discoid meniscus centrally (arrow) into weight bearing
portion of lateral compartment.

Cruciate Ligament Injury


MRI is the only noninvasive means of imaging the cruciate
ligaments. As described earlier, the sagittal imaging plane
of the knee examination is prescribed to approximate the
plane of the ACL. The normal ACL appears as a linear
band of hypointense bers interspersed with areas of intermediate signal. The ACL courses from its femoral attachment on the lateral condyle at the posterior extent of the
intercondylar notch to the anterior aspect of the tibial
eminence. The orientation of the normal ACL is parallel
to the roof of the intercondylar notch. Reliable signs of
ACL rupture include an abnormal horizontal course, a
wavy or irregular appearance, or uid-lled gaps in a discontinuous ligament (Fig. 2-14). Chronic tears can reveal
ligamentous thickening without edema or, often, complete
atrophy. Several secondary signs of ACL rupture exist. In
acute injuries, bone contusions are manifested as regions of
edema in the subchondral marrow, typically in the lateral
compartment. These contusions usually resolve within 6
weeks of the injury. Anterior translocation of the tibia with
respect to the femur, the MRI equivalent of the drawer
sign, is highly specic for acute or chronic tears. Buckling
of the posterior cruciate ligament often is present, but this
sign is more subjective. Although usually best evaluated in
the sagittal plane, the ACL can and should be seen in
coronal and axial planes as well. In large series correlated
with arthroscopic data, MRI has achieved an accuracy rate
of 95% in the assessment of ACL pathological conditions.
As is frequently the case with the physical examination,
MRI often is not helpful in differentiating partial from

Ch002-A03329.indd 138

complete tears. MRI can depict accurately the reconstructed ACL within the intercondylar notch and dene
the position of intraosseous tunnels. A thickened graft or
absence of the graft on MRI suggests graft failure. Because
the normal revascularization process may result in areas of
increased signal within and around the graft, edematous
changes should be interpreted with caution.
In extension, the posterior cruciate ligament is a gently
curving band of brous tissue, appearing as a homogeneously hypointense structure of uniform thickness on sagittal MRI series. Discontinuity of the ligament or uid
signal within its substance indicates a tear (Fig. 2-15). In
the coronal imaging plane, the medial collateral ligament
appears as a thin dark band of tissue closely applied to the
periphery of the medial meniscus. Mild injuries result in
edema around the otherwise normal ligament. Severe strain
or rupture causes ligamentous thickening or frank discontinuity (Fig. 2-16). Although mild degrees of medial collateral ligament injury correlate well with MRI appearance,
imaging is less accurate in grading more severe injuries.
Injuries of the lateral supporting structures, including the
bular collateral ligament, iliotibial band, biceps femoris,
and popliteus tendon, also are depicted with MRI.

Other Knee Problems


Severe injuries to the extensor mechanism of the knee are
clinically obvious, but when partial tears of the patellar or
quadriceps tendon are suspected, MRI can conrm the
diagnosis. Discontinuity of tendinous bers and uid in a
gap within the tendon are seen with complete tears.

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Chapter 2 Magnetic Resonance Imaging in Orthopaedics

139

B
Fig. 2-14 Acute ACL tear. A, Conventional proton densityweighted sagittal image shows
abnormal, more horizontal orientation of distal portion of torn ACL (arrows). B, T2-weighted
image at same location displays uid at site of avulsed femoral attachment (arrow).

Incomplete tears show thickening of the tendon with interspersed edema. Generally, tendinitis shows tendon thickening, while normal low signal is maintained. Posteriorly,
popliteal or Baker cysts are noted in the medial aspect of
the popliteal fossa. These cysts can rupture into the gastrocnemius muscles, mimicking thrombophlebitis. MRI

shows uid dissecting into this calf muscle. Caution should


be used when evaluating cystic popliteal fossa masses
because other lesions, such as popliteal artery aneurysms
and tumors, are common in this location. Demonstration
of the neck of a popliteal cyst at its communication with
the joint between the medial gastrocnemius and the semi-

Fig. 2-15 Posterior cruciate ligament tear. Sagittal T2weighted image shows abnormal bright signal (arrow) within
normally dark posterior cruciate ligament. Fluid also is seen
around proximal extent of partially torn posterior cruciate
ligament.

Fig. 2-16 Medial collateral ligament tear. Complete disruption of proximal medial collateral ligament (arrow) is shown
in coronal fat-suppressed, proton densityweighted image;
this appearance suggests grade 3 medial collateral ligament
injury.

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Part I General Principles

ries in children (Fig. 2-20) and in showing osteochondritis


dissecans (Fig. 2-21). T2-weighted or gradient-echo
sequences can show uid surrounding an unstable fragment. MRI also is helpful in determining the integrity of
the overlying cartilage. Fat-suppressed, fast spin-echo,
proton densityweighted, or gradient-echo sequences
obtained with volumetric technique are helpful in the
evaluation of articular cartilage in the knee and many other
joints (see Fig. 2-6). Enormous effort is being appled to
the noninvasive imaging of cartilage, and many promising
MRI techniques are on the near horizon.

HIP

Fig. 2-17 Popliteal fossa cyst. Axial proton densityweighted


image shows hyperintense uid extending from knee joint
into popliteal fossa between semimembranosus tendon (straight
arrow) and medial gastrocnemius tendon (curved arrow).

membranosus tendon avoids potential misdiagnosis (Fig.


2-17).
Other potential problems around the knee for which
MRI is well suited include osteonecrosis, synovial pathological conditions, osseous contusions (Fig. 2-18), and
occult fractures (Fig. 2-19). Direct coronal and sagittal
MRI is helpful in assessing complications of physeal inju-

MRI has become an extremely useful tool in the evaluation


of the hip and pelvis. With the unsurpassed ability to image
marrow in the proximal femur, MRI can detect a spectrum
of pathological conditions of the hip. Examination of the
hips can be performed with the main magnetic coil (body
coil). This technique allows evaluation of both hips at
once, which is important in patients who may have a bilateral pathological process, such as osteonecrosis. If unilateral
evaluation is sufcient, improved resolution is obtained
with the use of surface coils. When available, torso coils
with phased-array design combine improved signal for
high-resolution images with large eld-of-view coverage.
Spin-echo sequences usually are performed in axial and
coronal planes. Sagittal images also should be acquired
when investigating osteonecrosis.

B
Fig. 2-18 Patellar dislocation. A and B, Axial fat-suppressed, proton densityweighted images
through patellofemoral joint show regions of increased signal, representing marrow edema
beneath medial facet of patella (long arrow) and in lateral aspect of lateral femoral condyle (thick
arrow). This pattern of osseous contusion indicates recent lateral patellar dislocation. Note
hematocrit level in the joint effusion (arrowheads).

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Chapter 2 Magnetic Resonance Imaging in Orthopaedics

141

Fig. 2-19 Occult Salter II fracture of distal femur in 14-year-old boy. A, Coronal T1-weighted
image reveals ill-dened reduced signal in medial distal femoral metaphysis. B, Fat-suppressed,
T2-weighted image shows irregular hypointense fracture (arrow) surrounded by hyperintense
marrow edema. Edema continues along lateral physis, indicating extension of fracture.

Fig. 2-21 Chondral lesion. Fat-suppressed proton density


weighted sagittal image of knee reveals small, well-dened,
uid-lled, full-thickness defect in articular cartilage of posteromedial femoral condyle (arrow).

Fig. 2-20 Physeal bar in 12-year-old boy. Gradient-echo


sagittal image of knee shows interruption of posterior extent
of distal femoral physis (arrow). An osseous bridge has
resulted in posterior angulation of articular surface of distal
femur. Articular and physeal cartilage exhibit increased
signal with most gradient-echo techniques.

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Part I General Principles

Osteonecrosis
The most frequent indication for hip imaging is evaluation
of osteonecrosis because early diagnosis is desirable whether
nonoperative or operative treatment is considered. Although
initial radiographs usually are normal, scintigraphy or MRI
may conrm the diagnosis. Of the two techniques MRI is
the more sensitive in detecting early osteonecrosis and
delineates the extent of marrow necrosis better. The percentage of involvement of the weight bearing cortex of the
femoral head as dened by MRI may be helpful in predicting the success of operative treatment. On T1-weighted
images, the classic MRI appearance of osteonecrosis is that
of a geographical region of decreased marrow signal within
the normally bright fat of the femoral head (Fig. 2-22).
This area of abnormal signal frequently is surrounded by a
low-signal band, representing ischemic bone. T2-weighted
images reveal a second inner band of bright signal, and the
resulting appearance has been termed the double line
sign. This sign is essentially diagnostic of osteonecrosis.
The central area of necrotic bone can show various signal
patterns throughout the course of the disease, depending
on the degree of hemorrhage, fat, edema, or brosis.
Flattening of the femoral head, cartilage loss, and effusion
are seen in late cases of osteonecrosis.

Transient Osteoporosis
A second condition also well depicted with MRI is transient osteoporosis of the hip. This unilateral process, ini-

tially described in pregnant women in their third trimester,


is now most commonly seen in middle-aged men. Transient
osteoporosis is a self-limited process of uncertain etiology,
and many patients have later involvement of adjacent joints,
such as the opposite hip. Because of these characteristics,
some authors have suggested that the disease is related to
reex sympathetic dystrophy and the less common regional
migratory osteoporosis. Initial radiographs may be normal
or may reveal diffuse osteopenia of the femoral head, with
preservation of the joint space. The MRI appearance is that
of diffuse edema in the femoral head, extending into the
intertrochanteric region. Focal MRI signal abnormalities,
as seen in osteonecrosis, generally are not present in transient osteoporosis. Rarely, a tiny focal, often linear lesion
in the subcortical marrow in the weight bearing portion
of the femoral head indicates an insufciency fracture in
the demineralized bone. T1-weighted sequences depict
diffuse edema as relative low signal in contrast to background fatty marrow. The edema becomes hyperintense on
T2-weighted series and is accentuated when fat-suppression
techniques are used (Fig. 2-23). This marrow appearance
has been termed bone marrow edema pattern. Rare case reports
have documented this pattern presenting as the earliest
phase of osteonecrosis. For this reason, if initial radiographs
are normal, repeat lms 6 to 8 weeks after the onset of
symptoms should show osteopenia of the femoral head,
conrming the diagnosis of transient osteoporosis. Transient
osteoporosis of the hip generally resolves without treatment
within 6 months, and the radiographs and MRI appearance
return to normal.

B
Fig. 2-22 Corticosteroid-induced bilateral osteonecrosis of femoral head. A and B, Coronal
T1-weighted and inversion recovery images through both hips reveal geographical focus of
marrow replacement in weight bearing aspect of left femoral head, indicating osteonecrosis (solid
arrows). More advanced disease is seen in right femoral head with collapse of articular surface,
adjacent marrow edema (open arrows), and effusion.

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Chapter 2 Magnetic Resonance Imaging in Orthopaedics

143

B
Fig. 2-23 Transient osteoporosis of hip in 30-year-old man. A, Coronal T1-weighted image
reveals diminished signal intensity within right femoral head and neck. B, Coronal inversion
recovery sequence shows hyperintense bone marrow edema in more diffuse pattern than seen
in osteonecrosis.

Trauma
Frequently, MRI can be helpful in evaluation of the hip
after trauma. Radiographs often are negative or equivocal
for fracture of the proximal femur in elderly individuals.
Although bone scanning has been used to conrm or
exclude fracture, this study can be falsely negative in elderly

patients in the rst 48 hours after injury. The MRI abnormalities are apparent immediately, with linear areas of low
signal easily seen in the fatty marrow on T1-weighted
images, and surrounding edema seen with T2-weighted
images (Fig. 2-24). In addition, the anatomical information
provided can assist in determining the type of xation
required. Many radiographically occult fractures are con-

Fig. 2-24 Radiographically occult femoral neck fracture in elderly woman. A, Questionable
cortical disruption is noted on radiograph of left hip obtained after womans fall. B, Coronal
T1-weighted image conrms fracture of greater trochanter manifested as vertically oriented
band of reduced signal (curved arrow) within normal bright fat signal of femoral neck. C, Coronal
inversion recovery sequence shows edema at fracture.

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Part I General Principles

ned to the greater trochanter or incompletely traverse the


femoral neck and in certain patients may be treated
conservatively.
A great deal of effort has been directed at the evaluation
of the acetabular labrum. Original reviews of the accuracy
of conventional MRI in the assessment of labral pathological conditions were disappointing because of large eld-ofview images that lacked adequate resolution. The advent
of MRI arthrography of the hip has greatly improved
visualization of the cartilaginous labrum. The geometry of
the labrum of the hip displays a wide range of normal
variation in asymptomatic individuals. In patients with
mechanical hip symptoms or possible anterior impingement, the addition of an anesthetic injection at the time of
arthrography is useful in assessing for intraarticular origin
of pain. Additional work is needed to de ne precisely the
role of this technique in these patients.

MRI of the spine accounts for a large percentage of examinations at most centers. MRI allows a noninvasive evaluation of the spine and spinal canal, including the spinal cord.
The anatomy of the spine, cord, nerve roots, and spinal
ligaments is complex. Because these crucial structures are
small and can be adequately imaged only with the use of
surface coils, the spine usually is divided into three sections: cervical, thoracic, and lumbar. Thoracic and lumbar
spine studies are performed with conventional or phasedarray surface coils. The cervical spine can be studied with
a specically contoured posterior neck coil or a at license
plate coil. Spinal examinations usually include series
obtained in axial and sagittal planes. Coronal images may
be helpful in patients with scoliosis. There is no one correct
imaging construct, and the makeup of the study depends
on many factors, including the type and eld strength of
the magnet, the availability of hardware (coils) and software, and the preferences of the examiner. All studies
should produce images that can detect and dene pathological conditions of the cord, thecal sac, vertebral bodies,
and intervertebral discs.

bony structures, such as osteophytes and bone fragments,


still are better dened with CT, some examiners prefer CT
myelography in patients with radiculopathy in the cervical
spine. Regardless of the region of the spine being evaluated, sagittal images provide an initial evaluation of the
intervertebral discs and posterior longitudinal ligament.
Because of its high water content, a normal disc exhibits
signal hyperintensity on T2-weighted images. The aging
process results in a gradual desiccation of the disc material
and loss of this signal. Disc herniations or extrusions appear
as convex or polypoid masses extending posteriorly into the
ventral epidural space, frequently maintaining a signal
intensity similar to that of the disc of origin (Fig. 2-25).
Sagittal T2-weighted or gradient-echo images create a
myelographic effect and are useful in evaluating compromise of the subarachnoid space. Sagittal T1-weighted
images should be examined closely, however, to identify
narrowing of the neuroforamina. The normal bright fat
signal in the foramina provides excellent contrast to darker
displaced disc material. Far-lateral disc herniations are seen
best on selected axial images that are localized through disc
levels. Free disc fragments appear discontinuous with the
intervertebral disc, usually of intermediate T1-weighted
signal in contrast to the hypointense cerebrospinal uid. Of
greater signicance in the cervical and thoracic spine is the
ability of MRI to detect signicant spinal cord compromise. Edema within the cord is readily seen as hyperintensity with T2 weighting.
The terminology of pathological conditions of the intervertebral disc is confusing. In an effort to standardize terminology, Jensen et al. proposed the following terms. A
bulge is a circumferential, symmetrical extension of the disc
beyond the interspace around the end plates. A protrusion is
a focal or asymmetrical extension of the disc beyond the
interspace, with the base against the disc of origin broader
than any other dimension of the protrusion. An extrusion
is a more extreme extension of the disc beyond the interspace, with the base against the disc of origin narrower
than the diameter of the extruding material itself or with
no connection between the material and the disc of origin.
Finally, a sequestration specically refers to a disc fragment
that has completely separated from the disc of origin.

Intervertebral Disc Disease

Postoperative Back Pain

The most common indication for MRI of the spine is


evaluation of intervertebral disc disease. MRI currently is
the procedure of choice for screening patients with low
back or sciatic pain. In the lumbar and thoracic spine, MRI
has supplanted CT myelography because it is noninvasive
and less expensive. The combination of high soft-tissue
contrast and high resolution allows ideal evaluation of the
intervertebral discs, nerve roots, posterior longitudinal
ligament, and intervertebral foramen. Additionally, MRI
provides excellent delineation of the spinal cord. Because

In a patient with persistent postoperative back pain, residual


disc, epidural hematoma or abscess, and discitis must be
considered. Before the advent of intravenous gadolinium
contrast agents, making a distinction between recurrent or
residual disc material and scar often was impossible with
CT myelography or MRI; however, the use of these agents
has improved postoperative evaluation of the spine. After
gadolinium administration, repeat T1-weighted images
typically show enhancement of scar or brosis (Fig. 2-26).
Beyond the immediate postoperative period, disc material

SPINE

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145

C
Fig. 2-25 Cervical disc extrusion (herniation). A, T1-weighted sagittal image of cervical spine
reveals extruded C5-6 disc (arrow). B, Gradient-echo sagittal image produces myelographic
effect, showing displaced disc material (black arrow) isointense to nucleus pulposus. Anterior
osteophytes (white arrow) at this level are accentuated with gradient-echo technique. C, Gradientecho axial image shows right paracentral extrusion (arrow) effacing cervical cord.

(in the absence of infection) does not enhance. Epidural


hematomas and abscesses appear as collections within the
spinal canal, showing peripheral enhancement with gadolinium on T1-weighted images. Gadolinium contrast agents
also are helpful in postoperative evaluation of the spine for
discitis. Changes in the disc space and adjacent vertebral
end plates frequently are seen after surgery on the spine
even when complications do not occur, but the triad of
vertebral body end plate enhancement, disc space enhancement, and enhancement of the posterior longitudinal ligament is highly suggestive of postoperative discitis (Fig.
2-27). Correlation with the erythrocyte sedimentation
rate, gallium or tagged white blood cell radionuclide
imaging, and percutaneous aspiration often is necessary.

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Although diagnosis of disc space infection in a patient


who has not undergone surgery generally is more straightforward, the MRI appearance of degenerative disc disease
is varied and can be confusing. Although vertebral end
plate edema and even enhancement do occur in the absence
of infection, the presence of disc space enhancement
strongly suggests infection. Pyogenic infection and fungal
or tuberculous infection frequently are associated with epidural and paraspinal abscesses. In the lumbar spine, extension into the adjacent psoas muscles is best shown on axial
T2-weighted sequences because hyperintense uid and
edema invade the normal hypointense musculature.
Subligamentous spread of infection with relative sparing of
the intervertebral disc should raise the suspicion of tuber-

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Part I General Principles

Fig. 2-26 Recurrent lumbar disc extrusion (herniation). A, Sagittal T1-weighted image shows
intermediate signal intensity in L4-5 disc material (arrow) surrounded by hypointense cerebrospinal uid. B, Sagittal T2-weighted image shows displaced disc material contiguous with
intervertebral disc. Hyperintense cerebrospinal uid provides improved contrast. C, Sagittal T1weighted image after gadolinium administration shows enhancement of epidural venous plexus
(curved arrow) and overlying granulation tissue (arrowheads), but no enhancement of disc material.

Fig. 2-27 Postoperative discitis. A, Sagittal T1-weighted image exhibits reduced marrow signal
adjacent to narrowed L4-5 intervertebral disc (arrows). B, Sagittal T2-weighted image reveals
corresponding hyperintense areas of vertebral marrow edema (arrows). C, After administration
of gadolinium, sagittal T1-weighted image exhibits enhancement of vertebral marrow, intervertebral disc (curved arrow), and posterior longitudinal ligament (arrowhead).

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Chapter 2 Magnetic Resonance Imaging in Orthopaedics

culous spondylitis. Pyogenic and tuberculous infections


show abnormal enhancement with gadolinium administration. Abscesses, given the lack of central perfusion, enhance
only at the periphery.

Spinal Tumors
Although tumor imaging in general is discussed later in
this chapter, MRI has proven valuable in the assessment of
spinal neoplasms. Excellent delineation of vertebral body
marrow allows detection of primary and metastatic disease
with high sensitivity on T1-weighted sequences. Normally,
vertebral body marrow signal progressively increases with
age, a reection of a gradually higher percentage of fatty
marrow. Diseases such as chronic anemia result in a higher
percentage of hematopoietic marrow, diffusely diminishing
this T1-weighted signal. Vertebral tumor foci appear as
discrete areas of diminished T1 signal. As is typical with
tumors, these lesions become hyperintense to surrounding
marrow on T2-weighted studies and enhance with contrast
administration. Neoplasms that diffusely involve vertebral
marrow, such as multiple myeloma, are more problematic
because differentiation from hematopoietic marrow is
sometimes difcult.

Spinal Trauma
CT remains the most useful advanced imaging technique
for spinal trauma. The inherent contrast provided by bone
and unmatched spatial resolution makes CT the preferred
initial examination in trauma patients. MRI is helpful in
patients with suspected spinal cord injury, epidural hematoma, or traumatic disc herniation. Soft-tissue injuries,
such as ligamentous tears, can be identied in the acute
stage. Discontinuity of normally hypointense ligaments,
hemorrhage, and edema can be seen on sagittal T2-weighted
images. In the setting of trauma, MRI usually is reserved
for neurologically impaired patients whose CT examinations are negative or for patients in whom spinal fracture
reduction is planned to exclude associated disc pathology.
The role of MRI in evaluating nontraumatic compressed
vertebrae and in the exclusion of any underlying pathological condition is crucial. Preservation of normal marrow
signal in a portion of the compressed vertebral body, especially with a linear pattern of signal abnormality, suggests
a fracture caused by a benign process, such as osteoporosis.
Complete marrow replacement or incomplete replacement
with focal abnormal marrow signal at other levels should
prompt consideration of biopsy. The presence of an irregular or asymmetrical soft-tissue mass or convexity of the
dorsal vertebral cortex also suggests an underlying neoplasm. In questionable cases, a follow-up MRI scan at 6 to
8 weeks can show reconstitution of normal marrow signal
in osteoporotic fractures.

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147

SHOULDER
The indications for MRI evaluation of the shoulder include
three interrelated problems: rotator cuff tear, impingement,
and instability. The complex anatomy of the shoulder
requires oblique imaging planes and surface coil technique.
The typical MRI shoulder examination includes axial spinecho or gradient-echo sequences to evaluate the labrum.
Oblique coronal images prescribed in the plane of the
supraspinatus tendon best detect pathological conditions of
the rotator cuff. Oblique sagittal images conrm abnormalities of the cuff tendons and evaluate rotator cuff
muscles in cross section. Arthrography and MRI can detect
complete tears of the rotator cuff, and although the cost of
MRI is decreasing, arthrography remains a less expensive
procedure. Although arthrography shows full-thickness
tears and partial tears along the articular (inferior) surface,
MRI provides signicantly more information in a noninvasive fashion.

Pathological Conditions of the Rotator Cuff


Oblique coronal spin-echo imaging with T2 weighting
optimally detects most pathological conditions of the rotator
cuff. With the humerus in neutral to external rotation, the
oblique coronal plane is chosen parallel to the tendon of
the supraspinatus tendon. As is the case with all other
tendons, the tendons of the supraspinatus, infraspinatus,
and teres minor muscles normally maintain low signal on
all pulse sequences. Rotator cuff tears appear as areas of
increased T2-weighted signal, representing uid within the
tendon substance. This signal may traverse the entire
tendon substance, indicating a full-thickness tear (Fig. 228). Alternatively, intact cuff bers may persist along the
articular surface, bursal surface, or both, as seen in partialthickness tears. Fluid may be identied in the subacromialsubdeltoid bursa. In patients with large or chronic tears,
the cuff may be so atrophied that its identication is impossible. In these cases, uid freely communicates between the
glenohumeral joint and the subacromial bursa, and the
humeral head migrates superiorly. Excessive retraction of
the cuff tendons and atrophy of the cuff musculature
portend a poor surgical result.
Many examiners have used the term tendinosis or tendinopathy to describe focal signal abnormalities within the
cuff that do not achieve the signal intensity of uid on
T2-weighted images. Because artifacts frequently occur
within tendons on T1-weighted and gradient-echo images,
the diagnosis of rotator cuff tear should not be made in the
absence of discrete foci of T2-weighted uid signal abnormalities. Typically, areas of normal uid can be appreciated
elsewhere in the glenohumeral joint for reference. Diffuse
or focal signal abnormalities less intense than uid should
be considered tendinosis. Using conventional spin-echo
technique, MRI has shown 80% to 97% sensitivity in

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Part I General Principles

B
Fig. 2-28 Full-thickness rotator cuff tear. A, Oblique coronal T1-weighted image poorly differentiates normal tendon from pathological condition. B, At same location, oblique coronal
fat-suppressed, T2-weighted image clearly shows uid-lled, full-thickness tear (arrow) in supraspinatus tendon.

detecting full-thickness rotator cuff tears. For the assessment of partial tears, the sensitivity is 67% to 89%. The
addition of fat suppression has been shown to improve
detection of partial-thickness tears. MRI assessment of the
repaired rotator cuff should be done with caution. Increased
T2-weighted signal normally can be seen with a healing
tendon, likely representing areas of granulation tissue. For
this reason, the diagnosis of partial-thickness tears in the
postoperative shoulder should be avoided. Larger, uidlled, full-thickness defects and tendon retraction correlate
well, however, with failed repairs or retears. MRI arthrography may be helpful in the evaluation of the rotator cuff
after surgery.

the addition of intraarticular saline or contrast material


greatly improves evaluation of labral pathological conditions and the biceps tendon origin. After arthrographic
instillation of saline, T2-weighted images reveal a hypointense labrum surrounded by bright uid. A superior technique uses dilute gadolinium as a contrast agent, allowing
T1-weighted imaging (with improved signal-to-noise
ratio). Imaging is performed in a standard position with
the arm at the patients side (Fig. 2-30). Additional imaging
can be performed with the humerus in abduction and

Impingement Syndromes
Although impingement can be suggested by an imaging
technique, it remains a clinical diagnosis. MRI can be
helpful in conrming the clinical impression or providing
additional information. Imaging ndings that suggest the
possibility of impingement include narrowing of the subacromial space by spurs or osteophytes, a curved or hooked
acromial morphology, and signal abnormalities in the cuff
indicating tendinosis or tendinopathy.

Pathological Conditions of the Labrum


Much research has been directed at MRI evaluation of the
labroligamentous complex of the shoulder. The crosssectional anatomy of the normal labrum varies, and the
adjacent glenohumeral ligaments create many potential
diagnostic pitfalls (Fig. 2-29). For these reasons, conventional MRI evaluation of the glenohumeral joint for instability has achieved mixed results. Most authors agree that

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Fig. 2-29 Labral tear. Axial gradient-echo image through


glenohumeral joint shows anterior displacement of avulsed
anterior labral fragment (curved arrow). Hypointense middle
glenohumeral ligament (arrowhead) lies between labral fragment and subscapularis tendon and should not be mistaken
for portion of labrum.

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Chapter 2 Magnetic Resonance Imaging in Orthopaedics

149

joint opacication. In this technique, delayed intraarticular


enhancement is achieved by exercising the joint after intravenous administration of gadolinium. Although a less invasive technique, the degree of distention is less than that
achieved with direct arthrography.

Other Causes of Shoulder Pain


MRI can show other causes of shoulder pain, such as occult
fractures or osteonecrosis (Fig. 2-31). Pathological conditions of the tendon of the long head of the biceps, including
rupture, dislocation, or tendinitis, should be detected on
routine MRI examination. An uncommon cause of shoulder pain, suprascapular nerve entrapment, can be caused by
ganglion cysts of the spinoglenoid notch. Similar to ganglia
elsewhere, these lesions appear as lobular, multiseptate,
hyperintense collections on T2-weighted or gradient-echo
sequences (Fig. 2-32). The presence of these ganglia should
trigger a careful search for an associated labral injury. The
brachial plexus is not imaged on the routine shoulder MRI
examination, and if a pathological condition of the brachial
plexus is suspected, a study dedicated to this anatomical
region should be performed.

Fig. 2-30 Labral tear at MRI arthrography. On axial T1weighted image, small, avulsed anterior labral fragment is
displayed as linear low-signal abnormality (arrow) surrounded
by high-signal gadolinium.

external rotation for assessment of the inferior glenohumeral ligament and its origin. Anterior labral injuries are
best seen in the axial plane, whereas superior labral abnormalities, or superior labral anteroposterior lesions, are best
depicted in axial or coronal images. Using MRI arthrography, a sensitivity of 91% and a specicity of 93% have
been reported in the detection of pathological labral conditions. The accuracy of MRI in evaluation of superior labral
anteroposterior lesions is less. Some investigators have proposed indirect arthrography as an alternative method of

WRIST AND ELBOW


MRI has a more limited but growing role in the evaluation
of pathological conditions of the elbow and wrist. Successful
study of both articulations requires high-resolution images
that are best obtained with surface coil technique and

Fig. 2-31 Osteonecrosis


complicating comminuted fracture of proximal humerus.
A, Oblique coronal T1-weighted image shows displaced fracture through neck of proximal
humerus (curved arrow). Geographical region of abnormal marrow within articular fragment is
characteristic of osteonecrosis (long arrow). B, Oblique coronal fat-suppressed, T2-weighted
image shows hyperintense rim of reactive tissue (arrow) surrounding now hypointense fatty
avascular marrow.

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Part I General Principles

Other Pathological Conditions of the Hand


and Wrist
MRI has a limited role in the evaluation of carpal tunnel
syndrome. Although this remains a clinical diagnosis, axial
imaging with T2 weighting can clearly display masses
within the connes of the carpal tunnel and edema and
swelling of the median nerve. MRI is useful in detecting
marrow abnormalities in osteonecrosis, as seen in the lunate
in Kienbck disease (Fig. 2-34) or in the scaphoid after
fracture (Fig. 2-35). As in the ankle, tenosynovitis and
tendon injuries in the wrist and hand can be assessed (Fig.
2-36).

ELBOW
Soft-tissue ganglion in painful shoulder. Oblique
coronal fat-suppressed, proton densityweighted image of left
shoulder reveals homogeneous hyperintense lesion in spinoglenoid notch. Ganglia and other masses in this location can
be associated with suprascapular nerve entrapment. Note
subtle hyperintensity indicating edema in infraspinatus muscle
along posterior scapula related to denervation (arrow).
Fig. 2-32

high-eld systems. Often these joints are examined in the


extremity coil, requiring extension of the arm overhead
within the center of the magnetic eld. This position is
difcult to maintain for all but the most agile individuals.
Open MRI scanners alleviate this problem; however, there
usually is a tradeoff in reduced signal-to-noise ratio or
increased examination time. Dedicated wrist coils, when
available, or coupled surface coils also may allow imaging
of this articulation at the patients side. The MRI examination should be directed at solving a specic clinical problem
or question.

In the elbow, MRI is useful in assessment of the biceps and


triceps tendons. Although complete tears of these tendons
frequently are clinically apparent, MRI can assist in surgical planning (Figs. 2-37 and 2-38). MRI also can detect
partial tears. Conventional MRI and MRI arthrography
have a crucial role in the evaluation of medial instability
and the study of the ulnar collateral ligament (Fig. 2-39).
The ulnar collateral ligament normally is visible as a linear
hypointense structure along the medial aspect of the joint
on all sequences. Fluid is seen within and around the disrupted ligament. The insertion of the ulnar collateral ligament may have a variable MRI appearance, and MRI
arthrography may be helpful, especially in assessment of
partial-thickness ligament tears.

Carpal Ligament Disruptions


In the wrist, the most common indication for MRI is
evaluation of the intrinsic carpal ligaments. With proper
technique, injuries to the triangular brocartilage complex
can be demonstrated with MRI. The triangular brocartilage is composed of signal-poor brocartilage, and perforations in the triangular brocartilage appear as linear
defects or gaps lled with hyperintense uid on coronal
gradient-echo or T2-weighted pulse sequences (Fig. 2-33).
Although evaluation of the scapholunate and lunatotriquetral ligaments is more challenging, with optimal technique
and equipment, the integrity of these structures can be
consistently assessed. Before the advent of MRI, these ligaments were studied by arthrography, a method still preferred by some authors. The extrinsic carpal ligaments can
be identied with three-dimensional volumetric scanning
and subsequent reconstruction; however, the MRI assessment of these ligaments has little impact on treatment.

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Fig. 2-33 Triangular brocartilage perforation. Coronal fatsuppressed, proton densityweighted image of wrist shows
central perforation of triangular brocartilage (long arrow).
Note uid in distal radioulnar joint (curved arrow). Scapholunate
ligament (open arrow) is intact in this wrist.

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Chapter 2 Magnetic Resonance Imaging in Orthopaedics

Fig. 2-34 Osteonecrosis of lunate (Kienbck disease).


Coronal T1-weighted image of wrist shows loss of normal
high-signal fat in lunate (arrow), indicating osteonecrosis.

TUMOR IMAGING
Perhaps nowhere in orthopaedics has MRI had as profound
an impact as in the eld of surgical oncology. Exquisite
soft-tissue contrast combined with detailed anatomy and

Fig. 2-35 Osteonecrosis of scaphoid after fracture. Coronal


T1-weighted image shows reduced signal in proximal (straight
arrow) and distal (curved arrow) fragments, indicating osteonecrosis. Normal marrow signal is preserved in distalmost
aspect of scaphoid (open arrow).

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151

Fig. 2-36 Image of rupture of exor digitorum profundus


tendon in long nger made 2 weeks after repair. Sagittal
inversion recovery image shows abrupt discontinuity of
exor tendon (arrow) with laxity of more proximal tendon
segment.

multiplanar capability place MRI at the forefront of musculoskeletal tumor imaging methods. Excellent bone
marrow delineation is most helpful in dening tumor
extent and planning surgical and radiation therapy. MRI
frequently is helpful in dening aggressive and indolent
processes; however, the contribution of routine radiographs

Fig. 2-37 Rupture of distal biceps tendon. Sagittal inversion


recovery image of elbow shows ruptured distal biceps tendon.
Proximal tendon (arrow) has retracted several centimeters, and
edema is present in tissues anterior to brachialis muscle.

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Part I General Principles

Fig. 2-38 Avulsion of triceps tendon.


A, Sagittal fat-suppressed, proton
densityweighted image of elbow
shows avulsed triceps tendon (long
arrow) retracted proximally from olecranon (thick arrow). B, Sagittal fatsuppressed, T2-weighted image shows
hyperintense uid (arrows) in gap
between bone and detached tendon.

cannot be overemphasized. In tumor imaging, interpreting


MRI studies without radiographs is risky.
Most oncological MRI examinations are performed
after radiographic detection of a lesion or discovery of a
clinically palpable mass. Whether imaging bone or softtissue neoplasms, the basic concepts are similar. If the lesion
is sufciently small (<20 cm), surface coil technique is

Fig. 2-39 Partial ulnar collateral ligament tear at MRI


arthrography of elbow. Coronal fat-suppressed, T1-weighted
image reveals contrast tracking deep to ulnar attachment of
ulnar collateral ligament (arrow).

Ch002-A03329.indd 152

preferred. Larger masses or lesions in the pelvis or thigh


usually are best imaged in the body coil or with a phasedarray torso coil. Imaging should be performed in at least
two planes, one of which should be axial (or transverse).
This plane is most helpful in dening the relationship of
lesions to nearby muscles and neurovascular structures and
best shows extraosseous extension of bone tumors.
Compartmental anatomy also is best shown in this imaging
plane. The sagittal or coronal images dene the proximal
and distal extents of bone or soft-tissue involvement. T1weighted images are useful in identifying areas of marrow
replacement or edema. T2-weighted sequences delineate
soft-tissue extension because most neoplasms become
hyperintense in contrast to surrounding muscle and fat
(Figs. 2-40 and 2-41). The addition of fat-suppression techniques when available can prove invaluable in dening
subtle foci of tumor or edema. The role of intravenous
gadolinium in the study of musculoskeletal oncology is
expanding. In the evaluation of soft-tissue masses, contrastenhanced, T1-weighted images can differentiate solid from
cystic lesions and may assist in biopsy planning by distinguishing active from necrotic tumor. Because active tumor,
tumor edema, and granulation tissue all show enhancement, this enhancement cannot separate tumor from surrounding reactive changes. Dynamic contrast enhancement
has shown promise in distinguishing tumor from surrounding edema based on relative enhancement rates, but this
technique is not widely available. Currently, routine use of
intravenous gadolinium in the initial evaluation of neoplasm is probably unnecessary. Conversely, in a patient who
has undergone surgery, the presence of nodular areas of
contrast enhancement in the surgical bed suggests recurrent

5/31/2007 12:07:37 PM

Fig. 2-40 Giant cell tumor of distal radius.


A, Sagittal T1-weighted image obtained through
wrist shows sharply demarcated region of decreased
marrow signal (arrow) dening intraosseous extent
of neoplasm. B, Sagittal proton densityweighted
image obtained with fat suppression better denes
soft-tissue extension (arrowheads).

Fig. 2-41 Chondrosarcoma arising in osteochondroma. A, Radiograph reveals irregular ossication


throughout exostosis of distal femur. B, T1-weighted
coronal image shows hypointense marrow signal
within lesion and extension of this abnormal signal
into medullary canal of femur (arrows). C, Axial
fat-suppressed, T2-weighted image shows typical
hyperintensity of neoplastic tissue (arrows), in contrast to surrounding normal tissues.

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Part I General Principles

Fig. 2-42 Myxoid liposarcoma of


popliteal fossa. A, T1-weighted
sagittal image shows well-dened
homogeneous mass of intermediate signal intensity (arrow). B,
Sagittal T2-weighted image reveals
heterogeneous increased signal
within lesion. In contrast to
well-differentiated
liposarcoma,
fat signal generally is not seen in
this tumor subtype.

or residual neoplasm, and the use of intravenous gadolinium is advised in these patients. Preoperative MRI angiography with gadolinium enhancement can provide
important information regarding the blood supply of
extremely vascular lesions.
The differential diagnosis of most bone tumors is derived
from routine radiographs. The role of MRI is to dene the
extent of disease. With the exception of densely sclerotic
lesions, such as osteoid osteoma, MRI has replaced CT for
the assessment of skeletal tumors.

The detection of soft-tissue masses depends more on the


history and physical examination, given the infrequency of
radiographic abnormalities. Most soft-tissue lesions have a
nonspecic MRI appearance, typically isointense to muscle
on T1-weighted images and hyperintense to muscle and fat
on T2-weighted images (Fig. 2-42). Certain lesions do
exhibit signal patterns that allow a tissue-specic diagnosis.
Soft-tissue lipomas reveal homogeneous fat signal intensity
on all sequences (Fig. 2-43). Subcutaneous lipomas are
notoriously difcult to image because of the lack of con-

B
Intramuscular lipoma of soleus muscle. A, Coronal T1-weighted image through calf
shows marked fatty inltration of soleus muscle (arrow). B, Coronal inversion recovery image
shows complete suppression of fat signal within mass. Muscle bers exhibit slightly more signal
than dark fat (arrow).
Fig. 2-43

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155

Fig. 2-44 Soft-tissue hemangioma


of foot. A, Coronal T1-weighted
image of midfoot shows inltrating
mass of heterogeneous increased
signal (arrow). B, Corresponding
fat-suppressed, T2-weighted image
shows markedly increased signal
within mass (arrow). Morphology
and signal characteristics of this
lesion (hyperintense T1- and T2weighted signal) are typical of
hemangiomas.

trast with the surrounding subcutaneous fat. Certain subtypes of liposarcoma exhibit regions of fat and nonfat
signal. The diagnosis of lipoma should be restricted to
lesions that contain only fat and almost imperceptible
brous septa. Similar to their intraosseous counterparts,
soft-tissue hemangiomas show areas of bright signal on
T1- and T2-weighted studies (Fig. 2-44). These signal
characteristics result from the presence of fat and large
amounts of slow-owing blood within the lesion. Situated
within or around joints, pigmented villonodular synovitis
reveals marked T2-weighted hypointensity because of the

presence of hemosiderin (Fig. 2-45). For most soft-tissue


lesions, however, MRI is not diagnostic for any specic
histology, and the distinction between benign and malignant disease must be made with great caution.

SUMMARY
This discussion of MRI attempts to summarize its important role in orthopaedics. The advent of smaller, more
specialized coils allows higher resolution and smaller elds

B
Fig. 2-45 Pigmented villonodular synovitis. A, Sagittal T1-weighted image of foot shows
abnormal decreased signal intensity tissue surrounding midfoot (arrows). B, Sagittal T2-weighted
image reveals persistent signal hypointensity resulting from hemosiderin deposition (arrows).

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of view, while maintaining satisfactory image signal-tonoise ratios. Continued improvements in hardware and
software are expected to shorten imaging time further and
reduce the cost of this technique. Innumerable clinical situations in which MRI can be used have not been discussed.
The techniques described are widely available with most
commercial imaging systems. Optimal image quality can
be obtained only when meticulous attention is paid to
imaging technique by the radiologist and MRI technician.
Greater interaction between orthopaedists and radiologists
ensures that studies are performed appropriately to solve
the specic clinical problem.

References
General
Burstein D, Gray M: New MRI techniques for imaging cartilage,
J Bone Joint Surg 85A(suppl 2):70, 2003.
Heron C: Magnetic resonance imaging in joint disease, Br J Hosp
Med 51:97, 1994.
Ho CP: MR imaging of sports-related injuries, Magn Reson
Imaging 7:1, 1999.
Karchevsky M, Schweitzer ME, Morrison WB, et al: MRI ndings of septic arthritis and associated osteomyelitis in adults,
AJR Am J Roentgenol 182:119, 2004.
Resnick D, Kand HS, eds: Internal derangement of joints,
Philadelphia, 1997, Saunders.
Rubin SJ, Feldman F, Staron RB, et al: Magnetic resonance
imaging of muscle injury, Clin Imaging 19:263, 1995.
Foot and Ankle
Beltran J: Magnetic resonance imaging of the ankle and foot,
Orthopedics 17:1075, 1994.
Ferkel RD, Flannigan BD, Elkins BS: Magnetic resonance
imaging of the foot and ankle: correlation of normal anatomy
with pathologic conditions, Foot Ankle 11:289, 1991.
Frey C, Kerr R: Magnetic resonance imaging and the evaluation
of tarsal tunnel syndrome, Foot Ankle 14:159, 1993.
Higashiyama I, Kumai T, Takakura Y, et al: Follow-up study of
MRI for osteochondral lesions of the talus, Foot Ankle Int
21:127, 2000.
Ho CP: Magnetic resonance imaging of the ankle and foot, Semin
Roentgenol 30:294, 1995.
Hogan JF: Posterior tibial tendon dysfunction and MRI, J Foot
Ankle Surg 32:467, 1993.
Hubbard AM, Davidson RS, Meyer JS, et al: Magnetic resonance
imaging of skewfoot, J Bone Joint Surg 78A:389, 1996.
Lee JW, Suh JS, Huh YM, et al: Soft tissue impingement syndrome of the ankle: diagnostic efcacy of MRI and clinical
results after arthroscopic treatment, Foot Ankle Int 25:896,
2004.
Morrison WB, Schweitzer ME, Wapner KL, et al: Osteomyelitis
in feet of diabetics: clinical accuracy, surgical utility, and costeffectiveness of MR imaging, Radiology 196:557, 1995.
Oae K, Takao M, Naito K, et al: Injury of the tibiobular syndesmosis: value of MR imaging for diagnosis, Radiology
227:155, 2003.
Rijke AM, Goitz HT, McCue FC III, et al: Magnetic resonance
imaging of injury to the lateral ankle ligaments, Am J Sports
Med 21:528, 1993.
Roberts DK, Pomeranz SJ: Current status of magnetic resonance
in radiologic diagnosis of foot and ankle injuries, Orthop Clin
North Am 25:61, 1994.

Ch002-A03329.indd 156

Steinbronn DJ, Bennett GL, Kay DB: The use of magnetic resonance imaging in the diagnosis of stress fractures of the foot
and ankle, Foot Ankle Int 15:80, 1994.
Terk MR, Kwong PK: Magnetic resonance imaging of the foot
and ankle, Clin Sports Med 13:883, 1994.
Toye LR, Helms CA, Hoffman BD, et al: MRI of spring ligament tears, AJR Am J Roentgenol 184:1475, 2005.
Verhagen RA, Maas M, Dijkgraaf MJ, et al: Prospective study
on diagnostic strategies in osteochondral lesions of the talus:
is MRI superior to helical CT? J Bone Joint Surg 87B:41,
2005.
Knee
Boeree NR, Watkinson AF, Ackroyd CE, et al: Magnetic resonance imaging of meniscal and cruciate injuries of the knee, J
Bone Joint Surg 73B:452, 1991.
Cheung LP, Li KCP, Hollett MD, et al: Meniscal tears of the
knee: accuracy of detection with fast spin-echo MR imaging
and arthroscopic correlation in 293 patients, Radiology 203:508,
1997.
Dillon EH, Pope CF, Jokl P, et al: Follow-up of grade 2
meniscal abnormalities in the stable knee, Radiology 181:849,
1991.
Dipaola JD, Nelson DW, Colville MR: Characterizing osteochondral lesions by magnetic resonance imaging, Arthroscopy
7:101, 1991.
Friemert B, Oberlander Y, Schwarz W, et al: Diagnosis of chondral lesions of the knee joint: can MRI replace arthroscopy?
A prospective study, Knee Surg Sports Traumatol Arthrosc 12:58,
2004.
Graf BK, Cook DA, DeSmet AA, et al: Bone bruises on magnetic resonance imaging evaluation of anterior cruciate ligament injuries, Am J Sports Med 21:220, 1993.
Harper KW, Helms CA, Lambert HS, et al: Radial meniscal
tears: signicance, incidence, and MR appearance, AJR Am J
Roentgenol 185:1429, 2005.
Herzog RJ, Silliman JF, Hutton K, et al: Measurements of the
intercondylar notch by plain lm radiography and magnetic
resonance imaging, Am J Sports Med 22:2401, 1994.
Jee W, McCauley TR, Kim J, et al: Meniscal tear congurations:
categorization with MR imaging, AJR Am J Roentgenol 180:93,
2003.
Kelly MA, Flock TJ, Kimmell JA, et al: MR imaging of the
knee: clarication of its role, Arthroscopy 7:78, 1991.
Lim PS, Schweitzer ME, Bhatia M, et al: Repeat tear of postoperative meniscus: potential MR imaging signs, Radiology
210:183, 1999.
Liu SH, Osti L, Henry M, et al: The diagnosis of acute complete
tears of the anterior cruciate ligament: comparison of MRI,
arthrometry and clinical examination, J Bone Joint Surg 77B:586,
1995.
Lowenberg DW, Feldman ML: Magnetic resonance imaging
diagnosis of discoid medial meniscus, Arthroscopy 9:704, 1993.
Mackenzie R, Dixon AK, Keene GS, et al: Magnetic resonance
imaging of the knee: assessment of effectiveness, Clin Radiol
51:245, 1996.
Marks PH, Chew BH: Magnetic resonance imaging of knee ligaments, Am J Knee Surg 8:181, 1995.
Maurer EJ, Kaplan KA, Dussault RG, et al: Acutely injured knee:
effect of MR imaging on diagnostic and therapeutic decisions,
Radiology 204:799, 1997.
Maywood RM, Murphy BJ, Uribe JW, et al: Evaluation of
arthroscopic anterior cruciate ligament reconstruction
using magnetic resonance imaging, Am J Sports Med 21:523,
1993.

5/31/2007 12:07:41 PM

Chapter 2 Magnetic Resonance Imaging in Orthopaedics

157

McCauley TR: MR imaging evaluation of the postoperative


knee, Radiology 234:53, 2005.
Munk B, Lundorf E, Jensen J: Long-term outcome of meniscal
degeneration in the knee: poor association between MRI and
symptoms in 45 patients followed more than 4 years, Acta
Orthop Scand 75:89, 2004.
OConnor MA, Palaniappan M, Khan N, et al: Osteochondritis
dissecans of the knee in children: a comparison of MRI and
arthroscopic ndings, J Bone Joint Surg 84B:258, 2002.
Rubin DA: Update on the knee, Magn Reson Imaging 8:2,
2000.
Sansone V, de Ponti A, Paluello GM, et al: Popliteal cysts and
associated disorders of the knee: critical review with MR
imaging, Int Orthop 19:275, 1995.
Schatz JA, Potter HG, Rodeo SA, et al: MR imaging of anterior
cruciate ligament reconstruction, AJR Am J Roentgenol 169:223,
1997.
Tyson LL, Daughters TC Jr, Ryo RK, et al: MRI appearance of
meniscal cysts, Skeletal Radiol 24:421, 1995.
Ververidis AN, Verettas DA, Kazakos KJ, et al: Meniscal bucket
handle tears: a retrospective study of arthroscopy and the relation to MRI, Knee Surg Sports Traumatol Arthrosc 14:343,
2006.
Yacoubian SV, Nevins RT, Sallis JG, et al: Impact of MRI on
treatment plan and fracture classication of tibial plateau fractures, J Orthop Trauma 16:632, 2002.

Kim YM, Oh HC, Kim HJ: The pattern of bone marrow oedema
on MRI in osteonecrosis of the femoral head, J Bone Joint Surg
82B:837, 2000.
Koo KH, Kim R: Quantifying the extent of osteonecrosis of the
femoral head: a new method using MRI, J Bone Joint Surg
77B:875, 1995.
Lafforgue P, Dahan E, Chagnaud C, et al: Early-stage avascular
necrosis of the femoral head: MR imaging prognosis in 31 cases
with at least 2 years of follow-up, Radiology 187:199, 1993.
May DA, Purins JL, Smith DK: MR imaging of occult traumatic
fractures and muscular injuries of the hip and pelvis in elderly
patients, AJR Am J Roentgenol 166:1075, 1996.
Potter H, Moran M, Schneider R, et al: Magnetic resonance
imaging in diagnosis of transient osteoporosis of the hip, Clin
Orthop Relat Res 280:223, 1992.
Rizzo PF, Gould ES, Lyden JP, et al: Diagnosis of occult fractures
about the hip: magnetic resonance imaging compared with
bone scanning, J Bone Joint Surg 75A:395, 1993.
Schmid MR, Notzli HP, Zanetti M, et al: Cartilage lesions in
the hip: diagnostic effectiveness of MR arthrography, Radiology
226:382, 2003.
Stutley JE, Conway WF: Magnetic resonance imaging of the
pelvis and hips, Orthopedics 17:1053, 1994.
Tehranzadeh J, Kerr R, Amster J: MRI of trauma and sportsrelated injuries of tendons and ligaments: II. Pelvis and lower
extremities, Crit Rev Diagn Imaging 35:131, 1994.

Hip
Alam A, Willett K, Ostlere S: The MRI diagnosis and management of incomplete intertrochanteric fractures of the femur, J
Bone Joint Surg 87B:1253, 2005.
Asnis SE, Gould ES, Bansal M, et al: Magnetic resonance imaging
of the hip after displaced femoral neck fractures, Clin Orthop
Relat Res 298:191, 1994.
Edwards DJ, Lomas D, Villar RN: Diagnosis of the painful hip
by magnetic resonance imaging and arthroscopy, J Bone Joint
Surg 77B:374, 1995.
Evans PD, Wilson C, Lyons K: Comparison of MRI with bone
scanning for suspected hip fracture in elderly patients, J Bone
Joint Surg 76B:158, 1994.
Feldman F, Staron RB: MRI of seemingly isolated greater trochanteric fractures, AJR Am J Roentgenol 183:323, 2004.
Fordyce MJ, Soloman L: Early detection of avascular necrosis
of the femoral head by MRI, J Bone Joint Surg 75B:365,
1993.
Gabriel H, Fitzgerald SW, Myers MT, et al: MR imaging of hip
disorders, Radiographics 14:763, 1994.
Guerra JJ, Steinberg ME: Distinguishing transient osteoporosis
from avascular necrosis of the hip, J Bone Joint Surg 77A:616,
1995.
Haramati N, Staron RB, Barax C, et al: Magnetic resonance
imaging of occult fractures of the proximal femur, Skeletal
Radiol 23:19, 1994.
Hayes CW, Balkissoon AA: Magnetic resonance imaging of the
musculoskeletal system: II. The hip, Clin Orthop Relat Res
322:297, 1996.
Hernigou P, Lambotte JC: Volumetric analysis of osteonecrosis
of the femur: anatomical correlation using MRI, J Bone Joint
Surg 83B:672, 2001.
Hodler J, Yu J, Goodwin D, et al: MR arthrography of the hip:
improved imaging of the acetabular labrum with histological
correlation in cadavers, Am J Radiol 165:887, 1995.
Kassarjian A, Yoon LS, Belzile E, et al: Triad of MR arthrographic ndings in patients with cam-type femoroacetabular
impingement, Radiology 236:588, 2005.

Spine
An HS, Nguyen C, Haughton VM, et al: Gadolinium-enhancement characteristics of magnetic resonance imaging in distinguishing herniated intervertebral disc versus scar in dogs, Spine
19:2098, 1994.
An HS, Vaccaro AR, Dolinskas CA, et al: Differentiation
between spinal tumors and infections with magnetic resonance
imaging, Spine 16(suppl):334, 1991.
Bell GR, Stearns KL, Bonutti PM, et al: MRI diagnosis of
tuberculous vertebral osteomyelitis, Spine 15:462, 1990.
Boden SD, Davis DO, Dina TS, et al: Postoperative diskitis:
distinguishing early MR imaging ndings from normal postoperative disk space changes, Radiology 184:765, 1992.
Desai SS: Early diagnosis of spinal tuberculosis by MRI, J Bone
Joint Surg 76B:863, 1994.
Djukic S, Lang P, Morris J, et al: The postoperative spine:
magnetic resonance imaging, Orthop Clin North Am 21:603,
1990.
Harris JH, Yeakley JW: Hyperextension-dislocation of the cervical spine: ligament injuries demonstrated by magnetic resonance imaging, J Bone Joint Surg 74B:567, 1992.
Jensen MC, Brant-Zawadzki MN, Obuchowski N, et al: Magnetic
resonance imaging of the lumbar spine in people without back
pain, N Engl J Med 331:69, 1994.
Lederman HP, Schweitzer ME, Morrison WB, et al: MR imaging
ndings in spinal infections: rules or myths? Radiology 228:506,
2003.
Penta M, Sandhu A, Fraser RD: Magnetic resonance imaging
assessment of disc degeneration 10 years after anterior lumbar
interbody fusion, Spine 20:743, 1995.
Rothman SL: The diagnosis of infections of the spine by
modern imaging techniques, Orthop Clin North Am 27:15,
1996.
Sharif HS: Role of MR imaging in the management of spinal
infections, AJR Am J Roentgenol 158:1333, 1992.
Sharif HS, Morgan JL, al Shahed MS, et al: Role of CT and MR
imaging in the management of tuberculous spondylitis, Radiol
Clin North Am 33:787, 1995.

Ch002-A03329.indd 157

5/31/2007 12:07:41 PM

158

Part I General Principles

Thornbury JR, Fryback DG, Turski PA, et al: Disk-caused nerve


compression in patients with acute low-back pain: diagnosis
with MR, CT myelography, and plain CT, Radiology 186:731,
1993.
Yuh WTC, Zachar CK, Barloon TJ, et al: Vertebral compression
fractures: distinction between benign and malignant causes
with MR imaging, Radiology 172:215, 1989.
Shoulder
Deutsch A, Altcheck DW, Veltri DM, et al: Traumatic tears of
the subscapularis tendon: clinical diagnosis, magnetic resonance imaging ndings, and operative treatment, Am J Sports
Med 25:13, 1997.
Fritz RC, Helms CA, Steinbach LS, et al: Suprascapular nerve
entrapment: evaluation with MR imaging, Radiology 182:437,
1992.
Goodwin DW, Pathria MN: Magnetic resonance imaging of the
shoulder, Orthopedics 17:1021, 1994.
Goss TP, Aronow MS, Coumas JM: The use of MRI to diagnose
suprascapular nerve entrapment caused by a ganglion,
Orthopedics 17:359, 1994.
Green MR, Christensen KP: Magnetic resonance imaging of the
glenoid labrum in anterior shoulder instability, Am J Sports Med
22:493, 1994.
Gusmer PB, Potter HG: Imaging of shoulder instability, Clin
Sports Med 14:777, 1995.
Gusmer PB, Potter HG, Donovan WD, et al: MR imaging of
the shoulder after rotator cuff repair, AJR Am J Roentgenol
168:559, 1997.
Iannotti JP, Zlatkin MB, Esterhai JL, et al: Magnetic resonance
imaging of the shoulder, J Bone Joint Surg 73A:707, 1991.
Magee T, Shapiro M, Williams D: Comparison of high-eldstrength versus low-eld-strength MRI of the shoulder, AJR
Am J Roentgenol 181:1211, 2003.
Magee T, Williams D, Mani N: Shoulder MR arthrography:
which patient group benets most? AJR Am J Roentgenol
183:969, 2004.
Mengiardi B, P rrmann CWA, Gerber C, et al: Frozen shoulder:
MR arthrographic ndings, Radiology 233:486, 2004.
Miniaci A, Dowdy PA, Willits KR, et al: Magnetic resonance
imaging evaluation of the rotator cuff tendons in the symptomatic shoulder, Am J Sports Med 23:142, 1995.
Minkoff J, Stecker S, Cavaliere G: Glenohumeral instabilities and
the role of MR imaging techniques, Magn Reson Imaging 5:767,
1997.
Mohana-Borges AVR, Chung CB, Resnick D: Superior labral
anteroposterior tear: classication and diagnosis on MRI
and MR arthrography, AJR Am J Roentgenol 181:1449,
2003.
Nelson MC, Leather GP, Nirschl RP, et al: Evaluation of the
painful shoulder: a prospective comparison of magnetic resonance imaging, computerized tomographic arthrography,
ultrasonography, and operative ndings, J Bone Joint Surg
73A:707, 1991.
Palmer WE, Caslowitz PL, Chew FS: MR arthrography of the
shoulder: normal intraarticular structures and common abnormalities, AJR Am J Roentgenol 164:141, 1995.
Rai M, Firooznia H, Sherman O, et al: Rotator cuff lesions:
signal patterns at MR imaging, Radiology 177:817, 1990.
Recht MP, Resnick D: Magnetic resonance imaging studies of
the shoulder: diagnosis of lesions of the rotator cuff, J Bone
Joint Surg 75A:1244, 1993.
Reinus WR, Shady KL, Mirowitz SA, et al: MR diagnosis of
rotator cuff tears of the shoulder: value of using T2-weighted
fat-saturated images, AJR Am J Roentgenol 164:1451, 1995.

Ch002-A03329.indd 158

Sher JS, Uribe JW, Posada A, et al: Abnormal ndings on magnetic resonance images of asymptomatic shoulders, J Bone Joint
Surg 77A:10, 1995.
Sherman OH: MR imaging of impingement and rotator cuff
disorders: a surgical perspective, Magn Reson Imaging 5:721,
1997.
Singson RD, Hoang T, Dan S, et al: MR evaluation of rotator
cuff pathology using T2-weighted fast spin-echo technique
with and without fat suppression, AJR Am J Roentgenol 166:1061,
1996.
Tirman PF, Stauffer AE, Crues JV III, et al: Saline magnetic
resonance arthrography in the evaluation of glenohumeral
instability, Arthroscopy 9:550, 1993.
Waldt S, Burkart A, Imhoff AB, et al: Anterior shoulder instability: accuracy of MR arthrography in the classication of anteroinferior labroligamentous injuries, Radiology 237:578, 2005.
Waldt S, Burkart A, Lange P, et al: Diagnostic performance of
MR arthrography in the assessment of superior labral anteroposterior lesions of the shoulder, AJR Am J Roentgenol 182:1271,
2004.
Wang JC, Hatch JD, Shapiro MS: Comparison of MRI and
radiographs in the evaluation of acromial morphology,
Orthopedics 23:1269, 2000.
Elbow, Wrist, and Hand
Aaron JO: A practical guide to diagnostic imaging of the upper
extremity, Hand Clin 9:347, 1993.
Berger RA, Linscheid RL, Berquist TH: Magnetic resonance
imaging of the anterior radiocarpal ligaments, J Hand Surg
19A:295, 1994.
Bhat M, McCarthy M, Davis TR, et al: MRI and plain radiography in the assessment of displaced fractures of the waist of
the carpal scaphoid, J Bone Joint Surg 86B:705, 2004.
Cobb TK, Dalley BK, Posteraro RH, et al: Establishment of the
carpal contents/canal ratio by means of magnetic resonance
imaging, J Hand Surg 17A:843, 1992.
Dalinka MK, Meyer S, Kricun ME, Vanel D: Magnetic resonance imaging of the wrist, Hand Clin 7:87, 1991.
Escobedo EM, Bergman AG, Hunter JC: MR imaging of ulnar
impaction, Skeletal Radiol 24:85, 1995.
Eygendaal D, Heijboer MP, Obermann WR, et al: Medial instability of the elbow: ndings on valgus load radiography and
MRI in 16 athletes, Acta Orthop Scand 71:480, 2000.
Falchook FS, Zlatkin MB, Erbacher GE, et al: Rupture of the
distal biceps tendon: evaluation with MR imaging, Radiology
190:659, 1994.
Fritz RC, Brody GA: MR imaging of the wrist and elbow, Clin
Sports Med 14:315, 1995.
Fritz RC, Steinbach LS: Magnetic resonance imaging of the
musculoskeletal system: III. The elbow, Clin Orthop Relat Res
324:321, 1996.
Herzog RJ: Efcacy of magnetic resonance imaging of the elbow,
Med Sci Sports Exerc 26:1193, 1994.
Ho CP: Sports and occupational injuries of the elbow: MR
imaging ndings, AJR Am J Roentgenol 164:1465, 1995.
Huynh PT, Kaplan PA, Dussault RG: Magnetic resonance
imaging of the elbow, Orthopedics 17:1029, 1994.
Imeda T, Makamura R, Miura T, et al: Magnetic resonance
imaging in Kienbock disease, J Hand Surg 17B:12, 1992.
Lepisto J, Mattila K, Nieminen S, et al: Low-eld MRI and
scaphoid fracture, J Hand Surg 20B:539, 1995.
Munshi M, Pretterklieber ML, Chung CB, et al: Anterior bundle
of ulnar collateral ligament: evaluation of anatomic relationships by using MR imaging, MR arthrography, and gross
anatomic and histologic analysis, Radiology 231:797, 2004.

5/31/2007 12:07:41 PM

Chapter 2 Magnetic Resonance Imaging in Orthopaedics

Oneson SR, Timins ME, Scales LM, et al: MR imaging diagnosis of TFC pathology with arthroscopic correlation, AJR Am
J Roentgenol 168:1513, 1997.
Patten RM: Overuse syndromes and injuries involving the elbow:
MR imaging ndings, AJR Am J Roentgenol 164:1205, 1995.
Peh WC, Gilula LA, Wilson AJ: Detection of occult wrist fractures by magnetic resonance imaging, Clin Radiol 51:285,
1996.
Schwartz ML, Al-Zahrani S, Morwessel RM, et al: Ulnar collateral ligament injury in the throwing athlete: evaluation with
saline-enhanced MR arthrography, Radiology 197:297, 1995.
Shaken JR III, Palmer AK, Levinsohn EM, et al: Magnetic resonance imaging of the triangular brocartilage complex, J Hand
Surg 15A:552, 1990.
Timmerman LA, Schwartz ML, Andrews JR: Preoperative evaluation of the ulnar collateral ligament by magnetic resonance
imaging and computed tomography arthrography: evaluation
in 25 baseball players with surgical conrmation, Am J Sports
Med 22:26, 1994.
Trumble TE, Irving J: Histologic and magnetic resonance
imaging correlations in Kienbocks disease, J Hand Surg
15A:879, 1990.
Vo P, Wright T, Hayden F, et al: Evaluating dorsal wrist pain:
MRI diagnosis of occult dorsal wrist ganglion, J Hand Surg
20A:667, 1995.
Yu JS: Magnetic resonance imaging of the wrist, Orthopedics
17:1041, 1994.
Tumors
Berger FH, ver Straete KL, Gooding CA, et al: MR imaging of
musculoskeletal neoplasm, Magn Reson Imaging Clin N Am
8:929, 2000.
Berquist TH: Magnetic resonance imaging of primary skeletal
neoplasms, Radiol Clin North Am 31:411, 1993.
Blacksin MF, Ende N, Benevenia J: Magnetic resonance imaging
of intraosseous lipomas: a radiologic-pathologic correlation,
Skeletal Radiol 24:37, 1995.
Cohen IJ, Hadar H, Schreiber R, et al: Primary bone tumor
resectability: the value of serial MRI studies in the determination of feasibility, timing, and extent of tumor resection, J
Pediatr Orthop 14:781, 1994.
Elias DA, White LM, Simpson DJ, et al: Osseous invasion by
soft-tissue sarcoma: assessment with MR imaging, Radiology
229:145, 2003.
Frassica FJ, Khanna JA, McCarthy EF: The role of MR imaging
in soft tissue tumor evaluation: perspective of the orthopedic

Ch002-A03329.indd 159

159

oncologist and the musculoskeletal pathologist, Magn Reson


Imag Clin N Am 8:918, 2000.
Gaskin CM, Helms CA: Lipomas, lipoma variants, and well-differentiated liposarcomas (atypical lipomas): results of MRI
evaluations of 126 consecutive fatty masses, AJR Am J Roentgenol
182:733, 2004.
Greeneld GB, Arrington JA, Kudryk BT: MRI of soft tissue
tumors, Skeletal Radiol 22:77, 1993.
Hanna SL, Fletcher BD: MR imaging of malignant soft-tissue
tumors, Magn Reson Imaging 3:629, 1995.
Kransdorf MJ: Magnetic resonance imaging of musculoskeletal
tumors, Orthopedics 17:1003, 1994.
Lang P, Grampp S, Vahlensieck M, et al: Primary bone tumors:
value of MR angiography for preoperative planning and monitoring response to chemotherapy, AJR Am J Roentgenol 165:135,
1995.
Lang P, Honda G, Roberts T, et al: Musculoskeletal neoplasm:
perineoplastic edema vs. tumor on dynamic postcontrast MR
images with spatial mapping of instantaneous enhancement
rates, Radiology 197:831, 1995.
Levey DS, Park YH, Sartoris DJ: Imaging of pedal soft-tissue
neoplasms, J Foot Ankle Surg 34:411, 1995.
Muscolo DL, Makino A, Costa-Paz M, et al: Localized pigmented villonodular synovitis of the posterior compartment of
the knee: diagnosis with magnetic resonance imaging,
Arthroscopy 11:482, 1995.
Ozaki T, Hashizume H, Kawai A, et al: Ewings sarcoma of the
hand: magnetic resonance images and treatment, J Hand Surg
20A:441, 1995.
Rahmouuni A, Montazel J, Divine M, et al: Bone marrow with
diffuse tumor inltration in patients with lymphoproliferative
diseases: dynamic gadolinium-enhanced MR imaging,
Radiology 229:710, 2003.
Roberts CC, Liu PT, Colby TV: Encapsulated versus nonencapsulated supercial fatty masses: a proposed MR imaging classication, AJR Am J Roentgenol 180:1419, 2003.
Rupp RE, Ebraheim NA, Coombs RJ: Magnetic resonance
imaging differentiation of compression spine fractures or vertebral lesions caused by osteoporosis or tumor, Spine 20:2499,
1995.
Schima W, Amann G, Stiglbauer R, et al: Preoperative staging
of osteosarcoma: efcacy of MR imaging in detecting joint
involvement, AJR Am J Roentgenol 163:1171, 1994.
Swan JS, Grist TM, Sproat IA, et al: Musculoskeletal neoplasms:
preoperative evaluation with MR angiography, Radiology
194:519, 1995.

5/31/2007 12:07:42 PM

Arthrodesis of the
Ankle, Knee, and Hip
http://bookmedico.blogspot.com
Robert M. Pickering

Ankle ......................................... 163


Approaches for ankle
arthrodesis ............................... 165
Anterior approach ............................. 165
Transmalleolar (transfibular)
approach ..................................... 165
Posterior approach ............................. 165
Preparation of joint surfaces ....... 165
Fixation of arthrodesis ............... 165

Chapter 3

External fi xation .............................. 166


Internal fi xation ............................... 167
Bone grafting ............................. 169
Techniques .................................. 171
Arthroscopic ankle arthrodesis .............. 171
Tibiotalar arthrodesis ......................... 171
Tibiocalcaneal arthrodesis ................... 181

Arthrodesis with cancellous screw


fi xation ...................................... 196

Knee ........................................... 187

Total hip arthroplasty after


hip arthrodesis ........................ 202

Arthrodesis is an operation designed to produce bony


ankylosis of a diseased joint. It often is a satisfactory solution for infection, tumors, trauma, and paralytic conditions
and in certain cases of osteoarthritis and rheumatoid arthritis. Arthrodesis often results in stiffness in adjacent joints,
and in the lower extremity energy requirements for ambulation usually are increased. The ability to achieve nearly
normal activity levels, especially in young, vigorous
patients, often outweighs these disadvantages, however.
Also, it is now possible to convert hip, and possibly knee,
arthrodeses to satisfactory arthroplasties if necessary later
in life.
Arthrodesis can be intraarticular, extraarticular, or combined intraarticular and extraarticular. Extraarticular techniques are especially useful in treating children, because
much of childrens joint surfaces are cartilage, and in treating patients who have large amounts of necrotic bone or
active infection, as in tuberculosis. Intraarticular techniques
permit greater correction of deformity and are satisfactory
if adequate areas of healthy bone surfaces can be apposed.
If adequate bone is unavailable locally, bone graftspreferably autogenous, cancellous boneshould be added.
The bony surfaces in an arthrodesis must be held securely
together by internal or external fi xation. In complicated
situations, especially involving malposition, infection, or
poor soft-tissue coverage, the Ilizarov external fi xation
device has been useful (see Chapters 50 and 51).

Indications and results ................ 187


Techniques .................................. 188
Hip ............................................. 195
Indications and results ................ 195
Techniques .................................. 196

ANKLE
Arthrodesis of the ankle is performed more frequently than
arthrodesis of the hip or knee. The most common indication is posttraumatic arthritis (Fig. 3-1). Other indications
include rheumatoid arthritis, infection, neuromuscular
conditions, and salvage of failed total ankle arthroplasty.
Resection arthrodesis may be indicated for treatment of
bone tumors around the ankle. Ankle arthrodesis currently
is being performed more frequently in patients with neuropathic arthropathy with severe deformity, but complications, especially infection and nonunion, are more common
in these patients. Alvarez et al. reported successful tibiocalcaneal arthrodesis and no infections in seven ankles with
nonbraceable neuropathic deformity; their technique
included the use of an adolescent condylar blade plate, large
cannulated AO screws, and a special cancellous allograftantibiotic mixture.
The optimal position for ankle fusion is 0 degrees of
flexion, 0 to 5 degrees of valgus, and 5 to 10 degrees of
external rotation with slight posterior displacement of the
talus. This position is best attained by draping the lower
extremity so that the area from the toes to above the knee
is accessible.
Most current techniques of ankle arthrodesis achieve
fusion in 80% to 90% of patients. After arthrodesis, most
patients are satisfied with the relief of pain, but most have

163

Ch003-A03329.indd 163

5/31/2007 12:09:30 PM

C
Fig. 3-1 A, Posttraumatic arthritis. B, Fusion using Charnley compression device. C, Solid
arthrodesis.

Ch003-A03329.indd 164

5/31/2007 12:09:30 PM

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

limited hindfoot motion that makes walking on uneven


surfaces difficult. Few patients are able to run effectively.
The use of a rocker-bottom shoe with a solid-ankle,
cushioned-heel (SACH) foot may improve gait after
arthrodesis.
Since Charnley introduced the concept of compression
ankle arthrodesis, more than 30 techniques and countless
modifications have been described. Generally, these techniques can be divided by approachanterior, transmalleolar, or posteriorand by method of fi xationexternal or
internal. Regardless of the specific technique used, according to Mann, some general principles should be carefully
observed, as follows:
1. An attempt should be made to create broad, flat, cancellous surfaces that are placed into apposition to allow
fusion to occur.
2. The arthrodesis site should be stabilized with rigid
internal fi xation, if possible, or with external fi xation.
This may be difficult in patients with osteoporotic
bone.
3. The hindfoot should be aligned to the leg and the forefoot to the hindfoot to create a plantigrade foot.

Approaches for Ankle Arthrodesis


In many patients, the soft tissue covering the foot and ankle
contains little or no fatty tissue, and often the soft tissue is
abnormal because of previous trauma or surgery. The surgical approach for arthrodesis should strive to avoid placing
undue tension on the skin. When a skin flap is created, it
should be as thick as possible to diminish the possibility
of skin slough. An incision down to bone to create fullthickness skin flaps is recommended, if possible, when
operating through unstable or adherent skin; this may help
prevent skin slough.
The cutaneous nerves around the foot and ankle usually
are superficial and can easily be cut, caught up within scar
tissue, or stretched at the time of surgery. The location of
these nerves should be kept in mind when approaching the
ankle for arthrodesis, but avoiding all cutaneous nerves
embedded in scar is impossible in many instances.
Anterior Approach
An anterior approach, usually through the anterior tibial
tendon sheath, allows exposure of the entire ankle joint,
but limits access to the medial and lateral malleoli. An
anterolateral approach in the internervous plane between
the superficial peroneal and sural nerves, with or without
fibular osteotomy, provides excellent exposure of the ankle
joint and can be extended distally to expose the subtalar
joint; however, access to the medial malleolus is limited,
and an additional small anteromedial incision may be
needed.

Ch003-A03329.indd 165

165

Transmalleolar (Transfibular) Approach


A transmalleolar or transfibular approach provides exposure
similar to that of the anterolateral approach, but allows
slightly better access to the posterior aspect of the ankle
joint. Exposure is improved by medial and lateral transmalleolar osteotomies. Combining medial and lateral incisions
provides complete exposure of the joint and allows removal
of the malleoli if desired for cosmesis or reduction of deformity. Paremain, Miller, and Myerson described a miniarthrotomy technique, in which two 1.5-cm incisions are
used, one medial and one anterolateral.
Posterior Approach
The posterior approach can be used for isolated tibiotalar
fusion in patients with compromised anterior skin from
previous trauma or surgery. It is used more commonly,
however, for tibiotalar calcaneal arthrodesis, as described
by Campbell and Russotti et al. Hayes and Nadkarni
described an extensile posterior approach to the ankle
based on an extraarticular vertical calcaneal osteotomy
behind the subtalar joint; the plane of dissection follows an
internervous plane behind the fibula. According to the
authors, the posterior flap formed is hinged medially and
offers wide exposure to the back of the ankle and posterior
subtalar joint. They reported no wound healing problems
in 12 patients with osteoarthritis or rheumatoid arthritis.

Preparation of Joint Surfaces


The joint surfaces can be prepared for arthrodesis by simply
denuding the remaining articular cartilage and fishscaling the subchondral bone with a small osteotome or
gouge. This preserves the normal ankle joint contour and
results in minimal shortening of the extremity. Two parallel cuts, one through the distal tibia and one through the
talar dome, that resect a minimal amount of bone allow
excellent apposition of large cancellous surfaces and allow
translation of the talus posteriorly beneath the tibia; overall
shortening generally is less than 1 cm. Schneider et al.
described the use of an extramedullary alignment guide
from a total knee arthroplasty system (placed upside down)
to aid in making precise bony cuts for maximal cancellous
contact.

Fixation of Arthrodesis
Fixation can be obtained by one of three methods: compression with an external fi xator, large cancellous screws,
or intramedullary fi xation. In rheumatoid bone, it is difficult to achieve good purchase with large screws. External
fi xation carries with it the concern of pin track infection
in a patient who is taking corticosteroids and antimetabolites (prednisone and methotrexate). Adequate compression
of the arthrodesis site is possible even in osteoporotic bone;
however, the amount of compression (which is difficult to

5/31/2007 12:09:39 PM

166

Part II Arthrodesis

C
A

B
Fig. 3-2 Calandruccio triangular compression device. A, Two pins are inserted through talus
and two through tibia for additional compression and more rigid fi xation. Device allows for
some correction of equinus or dorsiflexion and varus or valgus angulation. B and C, Lateral
and posterior views of ankle with device in place.

measure) necessary for fi rm apposition of cancellous surfaces differs in patients with posttraumatic arthritis, osteoarthritis, and rheumatoid arthritis. As long as adequate
fi xation and compression are possible at the arthrodesis, the
specific type of device is of secondary importance.
External Fixation
Charnley fi rst described the use of an external fi xation
device for compression ankle arthrodesis, but this uniplanar
device did not provide rotatory stability. To overcome the
lack of adequate rigidity in all planes that was present with
the single-axis frame used by Charnley, Calandruccio
designed a triangular frame to produce compression and
control motion in all three planes (Fig. 3-2). A modified
design, the Calandruccio II compression device (Smith &
Nephew, Memphis, Tenn), is easier to apply and allows
more latitude in pin placement to avoid compromised areas
of skin or bone; the elimination of the metal crossbar has
made it easier to see the arthrodesis site on intraoperative
and postoperative radiographs (Fig. 3-3). Berman et al.
described a triangular external fi xation frame that included
a pin in the midtarsal area in addition to pins in the talus
and tibia. They suggested that this frame eliminates the
lever action of the foot and provides more rigid fi xation,
producing a higher rate of fusion (91% of 23 patients in
their series). The unilateral Orthofi x external fi xator
(Orthofi x, Inc., McKinney, Tex) uses conically tapered
pins to improve purchase and a tensioning device to apply
compression. Many commercially available devices provide
compression and stability in multiple planes.

Ch003-A03329.indd 166

Ring or circular external fi xators also have been used


to minimize pin track infection, but they are cumbersome
for the patient, require careful pin track care, and are
expensive. They can be used effectively, however, in
patients with poor bone quality, in revisions for nonunion,

Pin to clamp
set screw

4-mm skeletal
traction pin
(5-mm thread
diameter)
Tibial
component

Compression
bolt (4-, 5-, and
7-inch available)

Talar
component
Anterior
Posterior

Bolt to clamp
set screw

Fig. 3-3 The Calandruccio II compression device is easier


to apply, allows more latitude in pin placement, and eliminates difficulty in seeing arthrodesis on radiographs.

5/31/2007 12:09:39 PM

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

167

Fig. 3-4 AC, Transarticular cross-screw fi xation. (Redrawn from Maurer RC, Cimino WR,
Cox CV, et al: Transarticular cross-screw fi xation: a technique of ankle arthrodesis, Clin Orthop
268:56, 1991.)

or in salvage situations, such as failed total ankle arthroplasty or active infection. Hammerschlag reported successful fusion in 10 such patients with the use of a ring fi xator;
all patients were able to retain weight bearing ability while
the fi xator was in place. To minimize the risk of damaging
neurovascular structures or tendons during pin insertion,
the cross-sectional anatomy of the lower leg and ankle must
be kept in mind when applying an external fi xator for
ankle arthrodesis.
Internal Fixation
Proponents of internal fi xation cite several advantages over
external fi xation, including ease of insertion; patient con-

Lateral tibial
metaphysis

Talus
Distal fibula

Fig. 3-5 Fixation with one tibiotalar screw and one talotibial screw. (From Dennis DA, Clayton ML, Wong DA, et al:
Internal fi xation compression arthrodesis of the ankle, Clin
Orthop 253:212, 1990.)

Ch003-A03329.indd 167

venience; comparable rates of delayed union, malunion,


nonunion, and infection; and greater resistance to shear
stress. Moeckel et al. reported a 95% union rate in 40
arthrodeses with internal fi xation compared with a 78%
union rate in 28 arthrodeses with external fi xation. At
follow-up, both groups had good to excellent clinical
results in 93% of patients. Maurer et al. also reported a
higher rate of union using internal fi xation (35 of 35
arthrodeses) than with external fi xation (10 of 12
arthrodeses).
Cancellous screws in various configurations are most
commonly used for internal fi xation. Moran et al. reported
a 95% fusion rate in 101 arthrodeses secured with two
cancellous screws, and Moeckel et al. reported successful
fusion in 39 of 40 arthrodeses fi xed with two tibiotalar
screws inserted from the anteromedial to anterolateral
aspect of the tibia into the body of the talus. Mann et al.
recommended two parallel cancellous screws inserted from
the lateral process of the talus to engage the posteromedial
tibial cortex, emphasizing the excellent compression
obtained by the parallel orientation of the screws. Friedman
et al. found, however, that crossed screws were more rigid
than parallel screws, especially in resisting torsional stress.
Maurer et al. recommended transarticular cross-screw fi xation inserted through anteromedial and anterolateral incisions (Fig. 3-4). Dennis et al. used one lateral tibiotalar
screw and one talotibial screw (Fig. 3-5) to obtain fusion
in 15 of 16 arthrodeses; both screws can be inserted through
an anterolateral incision.
Holt et al. used an inside-out drilling technique to
place a posterolateral tibiotalar screw through the posterolateral tibial cortex into the head of the talus (Fig. 3-6A).
After the hole is drilled from the plafond out through the

5/31/2007 12:09:42 PM

168

Part II Arthrodesis

B
Fig. 3-7 Posterior screw fi xation. (From Swrd L, Hughes JS,
Howell CJ, et al: Posterior internal compression arthrodesis of
the ankle, J Bone Joint Surg 74B:752, 1992.)

C
Fig. 3-6 AC, Inside-out technique for screw fi xation.
(From Holt ES, Hansen ST, Mayo KA, et al: Ankle arthrodesis
using internal screw fi xation, Clin Orthop 268:21, 1991.)

posterolateral cortex, a small posterior skin incision is made


over the drill tip, and the drill is placed through the posterolateral tibial hole and advanced into the talus (Fig.
3-6B). Medial and lateral screws are added as needed to
secure fi xation (Fig. 3-6C).
Monroe et al. reported a fusion rate of 93% using rigid
internal fi xation with cancellous screws. Their technique
is a modification of that described by Holt et al. They used
a lateral transfibular approach, but preserved the posterior
soft-tissue sleeve on the fibula. The fibula was split in the
sagittal plane and fi xed to the lateral tibia and talus using
6.5-mm or 3.5-mm screws.
Swrd et al. described a technique of posterior internal
compression using two posterior cancellous screws with
washers inserted obliquely across the tibiotalar joint and
down into the neck of the talus. They added autogenous
cancellous bone chips from the iliac crest packed into a
deep slot cut in the joint (Fig. 3-7).
Ogilvie-Harris et al. showed in a biomechanical cadaver
study that three crossed screws generated significantly more
compression and resistance to torque across the arthrodesis
site than did two screws. They also found that better compression was obtained when the lateral screw was inserted
fi rst. They recommended placing one screw laterally, one
medially, and one anteriorly from the tibia to the talus (Fig.
3-8). Kish et al. also recommended using three cannulated
screws to fi x the ankle, one screw in each of three columns:
lateral, central, and medial (Fig. 3-9).
Various authors have reported the use of plates, screws,
Kirschner wires, Steinmann pins, intramedullary rods, and

Ch003-A03329.indd 168

absorbable screws, with varying degrees of success. Braly


et al. and Wang et al. reported good results with the use
of a lateral T-plate and cited as advantages better cosmetic
result, quicker fusion, and fewer complications than with
other fi xation methods. Rowan and Davey also reported a
high fusion rate (94%) and few complications with the use
of anterior AO T-plates in 33 patients. Gruen and Mears
used a posterior blade plate for late reconstruction of five
ankles with complex deformity (Fig. 3-10); three had
excellent results, and two had good results. They recommended posterior blade-plate fi xation for ankles with segmental bone loss, infected nonunion, or collapsed talar
body. Weltmer et al. reported good results with the use of
an anterior Wolf blade plate because of the minimal dissection required, and Mears et al. used an anterior tension
plate (Fig. 3-11) to obtain fusion in 14 of 17 arthrodeses;

Fig. 3-8 A and B, Screw position recommended by OgilvieHarris et al. Three screws were found to generate more
compression and resistance to torque than two screws. (From
Ogilvie-Harris DJ, Lieberman I, Fitsialos D: Arthroscopically
assisted arthrodesis for osteoarthritis ankles, J Bone Joint Surg
75A:1167, 1993.)

5/31/2007 12:09:46 PM

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

Fig. 3-9 Placement of screws in three columns of talus:


lateral, central, and medial. (Redrawn from Kish G, Eberhart
R, King T, et al: Ankle arthrodesis: placement of cannulated
screws, Foot Ankle 14:223, 1993.)

they recommended this method for ankles with minimal


deformity or bony destruction.
Moore et al. used intramedullary nails to obtain fusion
in 14 of 19 arthrodeses, all of which were performed as
salvage procedures. They recommended that this technique
be reserved for significant posttraumatic arthrosis and bone
loss after tibial plafond fracture, concomitant subtalar
arthrosis, severe osteopenia (e.g., in patients with rheumatoid arthritis), and neuropathic arthropathy. Stone and
Helal suggested that long trifi ns are appropriate in elderly
patients, in whom early weight bearing is desirable; they
should not be used in patients with subtalar joint motion
that should be preserved. Fujimori et al. also described an
intramedullary nail with fi nlike longitudinal ridges that
they developed for use in patients with rheumatoid arthritis. The four fi ns were added to the distal part of the nail

Achilles tendon

169

Fig. 3-11 Anterior tension plate fi xation. (Redrawn from


Mears DC, Gordon RG, Kann SE, et al: Ankle arthrodesis with
an anterior tension plate, Clin Orthop 268:70, 1991.)

to stabilize the tibiotalar and subtalar joints and produced


solid fusions in all 15 of their patients. Carrier and Harris
used vertical Steinmann pins for fi xation of five arthrodeses
in patients with severe rheumatoid arthritis, and all five
fused; they recommended this technique for rheumatoid
patients with osteopenia and decreased bone density. Quill
reported successful fusion in 36 (90%) of 40 tibiotalocalcaneal arthrodeses using an intramedullary nail. Their best
results (100% union, no complications) were in patients
with primary fusions for osteoarthritis or rheumatoid
arthritis. Kile et al. used straight, interlocked, intramedullary nails for tibiotalocalcaneal arthrodesis in 30 patients
with a variety of painful and disabling disorders, including
posttraumatic arthritis, failed ankle arthrodesis and failed
ankle arthroplasty, and osteonecrosis of the talus. They
preferred a posterior approach because it avoided previous
incisions, gave maximal exposure, allowed correction of
significant deformities, and provided a large surface area
for bone grafting; 26 (86%) of the 30 patients were satisfied
with their results.

Bone Grafting
Blade plate

Calcaneus
Fig. 3-10 Posterior blade plate fi xation. (Redrawn from
Gruen GS, Mears DC: Arthrodesis of the ankle and subtalar
joints, Clin Orthop 268:15, 1991.)

Ch003-A03329.indd 169

Adding bone grafting to compression has been reported to


hasten fusion and increase the fusion rate. Chuinard and
Peterson described a method of ankle arthrodesis using a
full-thickness graft from the ilium forced between the
denuded surfaces of the tibia and talus. This method is
especially applicable in children because it does not damage
the distal tibial physis. Stauffer described a modification of
the Chuinard and Peterson technique for arthrodesis after
failed total ankle arthroplasty (Fig. 3-12). Campbell et al.
used vertically placed corticocancellous iliac bone grafts for
ankle arthrodesis when large bony defects were present.
Dowel techniques have been described by Hone, Pridie,

5/31/2007 12:09:48 PM

170

Part II Arthrodesis

or placed as onlay grafts. Bishop et al. reported the use of


free vascularized autogenous bone grafts for reconstruction
of 11 ankles with segmental bone loss caused by osteomyelitis, tumor, or trauma; successful fusion was obtained in
9 of the 11 ankles.
Paremain et al. reported 15 miniarthrotomy arthrodeses in which bone slurry, created when subchondral
bone was resected with a high-speed cutting tool, was
used for local bone graft. Union was radiographically
evident in all 15 arthrodeses at an average of 6 weeks.

Fig. 3-12 Chuinard and Peterson arthrodesis for failed total


ankle arthroplasty. A and B, Before surgery. C and D, After
surgery. Note graft between tibia and talus.

Ottolenghi et al., and Baciu and Filibiu. Stranks et al.


described a technique that combines an anterior approach
with a dowel bone grafting technique and screw fi xation.
They obtained solid fusions in 19 of 20 ankles. Dowel graft
techniques are applicable only when no significant deformity is present. Marcus et al. described a transmalleolar
technique that involves a dome osteotomy, tibial onlay
graft, and internal fi xation with staples and screws.
The variety of bone grafting techniques described in the
literature can help in adapting ankle arthrodesis to many
different situations. A tricortical block of iliac crest, split
carefully between the two tables, can be wedged into a
2.5-cm wide trough in the tibia and talus with the cancellous side facing the tibia bed (Fig. 3-13A). A sliding graft,
approximately 2 cm wide, 1 cm deep, and 8 to 10 cm long,
can be taken from the anterior, lateral, or medial tibia and
impacted into a tunnel created in the talar neck (Fig.
3-13B) or talar bed (Fig. 3-13C). A central bone graft (Fig.
3-13D) has been recommended for tubercular or rheumatoid ankles; the hole bored across the ankle also can be
fi lled with cancellous bone graft from the iliac crest. The
medial and lateral malleoli can be used as local bone grafts

Ch003-A03329.indd 170

B
Fig. 3-13 Types of bone grafts used in ankle arthrodesis. A,
Tricortical block of iliac crest wedged between tibia and
talus. B and C, Sliding graft impacted into tunnel in talar
neck or talar bed (C). D, Central bone graft inserted in hole
bored across ankle. (From Ouzounian TJ, Kleiger B: Arthrodesis
in the foot and ankle. In Jahss MH, ed: Disorders of the foot and
ankle: medical and surgical management, 2nd ed, Philadelphia, 1991,
Saunders.)

5/31/2007 12:09:50 PM

171

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

They recommended this technique for treatment of severe


degenerative changes in ankles with minimal deformity.
Crosby et al. reported a 55% complication rate using
demineralized bone matrixbone marrow slurry from the
iliac crest with arthroscopic ankle arthrodesis, although
most complications were minor. They concluded that compared with arthroscopic ankle arthrodesis without bone
grafting, the graft substitute does not increase the fusion
rate.

Techniques
Arthroscopic Ankle Arthrodesis
Several authors have reported success with arthroscopically
assisted ankle arthrodesis, citing as advantages quicker
fusion because of the limited exposure and less extensive
periosteal stripping and preservation of the overall contour
of the ankle mortise, giving a better cosmetic result. In a
comparison of arthroscopic and open techniques, Myerson
and Quill reported 94% union in an average of 8.7 weeks
with the arthroscopic technique and 100% union at an
average of 14.5 weeks with the open technique. Cameron
and Ullrich reported that 5 of 15 patients with arthroscopic
ankle fusions required further surgery to correct complications related to infection, painful hardware, or subtalar
joint arthritis, even though all 15 patients had fusion at an
average of 3 months. Corso and Zimmer obtained fusion
at an average of 9.5 weeks in all 16 of their patients with
osteoarthritis or rheumatoid arthritis. Glick et al. reported
a 97% fusion rate in 34 ankles at an average time of 9
weeks without infection or neurological injury. The
arthroscopic technique is technically difficult and timeconsuming, however, and can be used only in ankles with
minimal deformity. More recently, OBrien et al. compared the results of 19 arthroscopic ankle fusions with 17
open arthrodeses and found similar rates of fusion (84%
and 82%). Nonunions occurred in 18% of the patients
treated with open ankle fusion and in 16% of patients
treated arthroscopically. Although these authors found no
statistical significance in the operative times between the
two groups, tourniquet times, estimated blood loss, and
hospitalization were significantly less for the arthroscopically treated group. Postoperative complications occurred
in five patients who had open arthrodesis, but no complications were noted after arthroscopic fusion. Arthroscopic
ankle arthrodesis is described in Chapter 48.
Tibiotalar Arthrodesis
Tibiotalar arthrodesis is the most frequently performed
arthrodesis around the ankle. When done for isolated ankle
arthrosis, results usually are satisfactory, but ankles with
severe malalignment or bone deficiency (e.g., after failed
total ankle arthroplasty), major soft-tissue problems, infection, osteonecrosis, or neuropathy generally require a more
extensive procedure.

Ch003-A03329.indd 171

High rates of successful fusion have been reported with


a variety of techniques and modifications of tibiotalar
arthrodesis. The techniques described here are those currently used most often and with which we have had the
most experience and success; this is not to imply that other
techniques cannot obtain equally good results.

Tibiotalar Arthrodesis with an Iliac Crest


Bone Graft
TECHNIQUE 3-1

Chuinard and Peterson

Make an anterior longitudinal incision over the ankle joint, and


develop the approach between the extensor hallucis
longus and the extensor digitorum longus tendons (Fig. 3-14A).
Retract medially the anterior tibial vessels and nerve, and
detach the capsule of the ankle joint from the anterior margin of
the tibia.
With an osteotome and mallet, remove the articular cartilage
from the horizontal surfaces of the tibia and talus, but not from
the vertical surfaces of these bones or the fibula (Fig. 3-14B and
C). Correct any deformity by removing appropriate wedges of
bone. Take care to avoid injuring the distal tibial physis in
children.
With an osteotome the same width as the ankle mortise,
remove a full-thickness graft from the anterior iliac crest as wide
as the mortise and as long as the anteroposterior dimension of
the ankle. Do not include the anterior superior iliac spine. Tailor
the graft to fit the mortise, and perforate it with a drill (Fig.
3-14D).
Manually distract the ankle joint, and pound the graft into
place with the wide rim facing anteriorly and the surfaces of the
graft firmly apposed to the surfaces of the tibia and talus (Fig. 314E to G). Check the position of the foot and adjust it to neutral.
Fill any remaining recesses with cancellous bone from the ilium.
Close the wound, and apply a cast from the base of the toes
to the proximal thigh with the knee flexed 15 degrees.

AFTERTREATMENT

After 2 weeks, the cast is either windowed or changed, and the sutures are removed. After 6
weeks, a cast is applied from the base of the toes to below
the knee. After 2 to 3 months, walking in a cast is begun,
and after 3 to 4 months, a short leg brace with a rigid ankle
joint is fitted and worn until a solid fusion is shown.

Tibiotalar Arthrodesis with Screw Fixation


TECHNIQUE 3-2

Mann et al.

Before surgery, carefully evaluate the alignment of the normal


and abnormal limbs to determine correct rotation. This usually
can be done by aligning the tibial tubercle with the second
metatarsal.

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172

Part II Arthrodesis

E
Fig. 3-14 Chuinard and Peterson technique of arthrodesis of ankle. A, Skin incision. B,
Articular cartilage is removed from superior surface of talus. C, Articular cartilage is removed
from inferior surface of tibia. D, Iliac graft is perforated with drill. E, Graft is inserted with
its wide rim facing anteriorly. F and G, Lateral and anterior views of ankle with graft in place.
(Redrawn from Chuinard EG, Peterson RE: Distraction-compression bone graft arthrodesis of the
ankle: a method especially applicable in children, J Bone Joint Surg 45A:481, 1963.)

Tibiotalar Arthrodesis with Screw Fixation


TECHNIQUE 3-2

Mann et al.contd

Apply and inflate a thigh tourniquet, and place a sandbag


under the ipsilateral hip to improve exposure of the lateral side
of the foot and ankle.
Begin the skin incision approximately 10 cm proximal to the tip
of the fibula, and carry it down along the fibular shaft, then
slightly distally another 10 cm toward the base of the fourth
metatarsal (Fig. 3-15A). This incision passes through an
internervous space between the sural nerve posteriorly and the
superficial peroneal nerve anteriorly.

Develop skin flaps to create a full-thickness flap along the


skeletal plane.

Ch003-A03329.indd 172

Strip the periosteum from the fibula anteriorly and posteriorly,


and carry the incision distally to expose the posterior facet of the
subtalar joint and the sinus tarsi area. Carry the dissection across
the anterior aspect of the tibia and the ankle joint.
With a periosteal elevator, strip the soft tissue from the distal
end of the tibia, ankle joint, and talar neck to the area of the
medial malleolus.
Osteotomize the fibula approximately 2 cm proximal to the
level of the ankle joint, and bevel it so as not to leave a sharp
prominence.
Remove the distal portion of the fibula by sharp and blunt
dissection to expose the lateral aspect of the tibia and ankle joint
and the posterior facet of the subtalar joint.

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173

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

Sural
nerve

Superficial
peroneal nerve

Incision
Resected
area

Sinus tarsi

D
C
Fig. 3-15 Tibiotalar arthrodesis with screw fi xation (see text). A, Skin incision. B, Cuts in
fibula, tibia, and talus. C, Entry points for screws. D, Placement of 6.5-mm screws across
arthrodesis site. (From Mann RA: Arthrodesis of the foot and ankle. In Mann RA, Coughlin MJ,
eds: Surgery of the foot and ankle, 6th ed, St Louis, 1993, Mosby.)

Make an incision through the deep fascia along the posterior


aspect of the tibia (which was exposed by removal of the end of
the fibula), and gently move a periosteal elevator across the
posterior aspect of the tibia and then toward the calcaneus
medially to strip the soft tissue from the posterior aspect of the
tibial and ankle joint.
Place malleable retractors anteriorly and posteriorly around the
distal end of the tibia to expose the ankle mortise.

across the ankle joint, and remove the entire medial malleolus
through a separate medial incision.

Place the foot into proper alignment (0 degrees of


dorsiflexionplantar flexion and about 5 degrees of valgus), and
make a cut in the superior aspect of the talus to remove 3 to
4 mm of bone. Make this cut parallel to the one in the distal end
of the tibia.

sagittal saw, cutting as perpendicular as possible to the long axis


of the tibia. Remove as little bone as possible from the dome of
the ankle joint. Bring the cut across the ankle joint, stopping just
where the curve of the medial malleolus begins (Fig. 3-15B).

Bring the bone surfaces together, and carefully check


alignment. If any malalignment is present, remove more bone
from the distal end of the tibia or occasionally from the talus to
align the joint properly. If the joint surfaces do not come
together without any tension, the medial malleolus is too long
and should be shortened.

Free the tibial fragment medially by placing a broad osteotome


into the osteotomy and gently levering distally to break its
attachment to the medial malleolus; remove the fragment. If the
bone is porotic or if the deformity is significant, continue cutting

Approach the medial malleolus through a longitudinal 6-cm


anteromedial incision. Taking care to avoid the saphenous nerve,
carry the incision down through subcutaneous tissue and fat to
expose the medial malleolus.

Make the initial cut in the distal part of the tibia with a small

Ch003-A03329.indd 173

5/31/2007 12:09:54 PM

174

Part II Arthrodesis

Tibiotalar Arthrodesis with Screw Fixation


TECHNIQUE 3-2 Mann et al.contd
Remove the periosteum and deltoid ligament to expose the tip
of the malleolus and use a sagittal saw or osteotome to remove
the distal 1 cm. Take care not to cut the posterior tibial tendon
inadvertently; it lies just posterior to the medial malleolus.
The joint surface now can be easily apposed to obtain
satisfactory alignment. Line up the anterior edge of the tibia and
the anterior cut edge of the talus to align the ankle joint in the
anteroposterior plane. If the talus is not placed far enough
posteriorly, the normal posterior slope of the calcaneus will be
absent.

Stabilize the talus to the tibia with a towel clip, a bone clamp,
or Kirschner wires. Carefully check alignment to ensure correct
varus-valgus and dorsiflexionplantar flexion and the proper
degree of rotation.
With a 3.5-mm bit, drill two holes across the arthrodesis site,
one beginning within the sinus tarsi area and the other just
above the lateral process (Fig. 3-15C). As the initial hole is drilled
in the sinus tarsi, invert the calcaneus as much as possible, and
hold the drill bit almost parallel to the floor as it passes out
medially through the distal end of the tibia. Disconnect this bit
from the drill, and use a second bit to drill a hole just above the
lateral process, almost parallel to the first drill bit. Carefully check
alignment again. Remove one of the drill bits and measure the
depth of the hole; tap the hole and insert a 6.5-mm screw (Fig.
3-15D).

Usually a 50- to 60-mm long compression screw with 32-mm


threads is used. If the threads do not completely cross the
arthrodesis site, use a short threaded screw. It is important that
the threads engage the cortex of the tibia to gain maximal
compression. Place the screw in the lateral process high enough
that it does not impinge against the posterior facet. In patients
with soft bone, a washer can be used.
The fibula is not replaced, and generally no problems with
peroneal tendon function occur.
If there is room for any bone graft, some can be packed into
the space between the medial malleolus (if it was left in place)
and the medial aspect of the talus.

Close the wound in layers over a suction drain, and apply a


thick compression dressing with plaster splints.

AFTERTREATMENT The suction drain usually is removed


the day after surgery, and the surgical dressing and sutures
are removed at 10 days. A short leg, nonweight bearing
cast is applied, or if the patient is unreliable, a long leg cast
with the knee flexed to 60 degrees is worn. The cast is
removed 6 weeks after surgery, and union is checked on
radiographs. If satisfactory early union is occurring, a short
leg, weight bearing cast is applied and is worn until fusion
occurs, usually within 10 to 14 weeks after surgery.

Ch003-A03329.indd 174

Tibiotalar Arthrodesis through


Miniarthrotomy
The miniarthrotomy technique involves a limited resection
of the joint surfaces through two small anterior incisions.
Miller, Paremain, and Myerson reported a fusion rate of
98% (46 of 47) in two groups of patients with miniarthrotomy arthrodeses. They recommended this technique
for patients with minimally deformed ankles (Fig. 3-16).

TECHNIQUE 3-3

Miller, Paremain, and Myerson

With the patient supine, administer a regional ankle block (see


Chapter 77) with intravenous sedation; general anesthesia can be
used if necessary.
Make two 1.5-cm incisions, one anteromedial and one
anterolateral, in approximately the same positions as the portals
for the standard arthroscopic technique (Fig. 3-17). Make the first
incision medial to the anterior tibial tendon and the second
lateral to the peroneus tertius tendon (to avoid the dorsal
cutaneous branch of the superficial peroneal nerve).
Using angled curets, resect the cartilage of the anterior ankle
joint; small rongeurs are helpful in dbriding the synovium and
cartilage.
Place a small lamina spreader, modified by having the teeth
removed, alternately in the medial and lateral incisions to view
the joint surface to be resected.
Irrigate the ankle with saline.
Place a pneumatic long-burr resector (AM 10-bit; Midas Rex,
Forth Worth, Tex) into the joint, and dbride any further
cartilage and bone to the subchondral level. This burr generates
a bone slurry that can be collected for later use as a bone
graft. The posterior third of the ankle joint cannot be resected
with this technique.
Using the burr, carefully dbride the medial and lateral gutters.
Position the ankle in 5 degrees of valgus, 0 degrees of
dorsiflexion, and neutral rotation.
Place guidewires for 6.8-mm or 7.3-mm cannulated selfdrilling, self-tapping screws from the anteromedial tibia into the
body of the talus and from the distal posterolateral tibia into the
head of the talus. A third screw can be placed from the fibula
into the talus if needed for stability.
Alternatively, place three cannulated screws percutaneously
from the tibia into the talus with fluoroscopy to confirm
placement and screw length.

Pack the bone slurry around the joint, and close the joint
capsule carefully to prevent leakage of the slurry.
After routine closure, apply a bulky cotton dressing with a
coaptation-type splint and posterior mold of plaster.

5/31/2007 12:09:55 PM

175

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

D
Fig. 3-16

AD, Miniarthrotomy technique.

AFTERTREATMENT The splint is left in place for 2 weeks.


After its removal, a short leg cast is applied, and the patient
is maintained in nonweight bearing status until radiographic signs of healing are present (usually 4 to 6 weeks).
At that time a walking cast is applied with a posteriorly
placed rubber heel (to apply axial rather than torque forces
across the fusion); this cast is worn until the arthrodesis is
clinically and radiographically solid. The patient can then
be weaned to a commercially available walking boot followed by regular shoes.

Ch003-A03329.indd 175

Compression Arthrodesis of the Ankle


Using the Calandruccio II External Fixation
Device
TECHNIQUE 3-4
Place the patient supine, and apply a tourniquet. Drape the
leg above the knee.

Use an anterolateral approach with distal extension of


the incision to expose the head and neck of the talus and

5/31/2007 12:09:55 PM

Concentric remodeling to obtain a ball-and-socket (Fig.


3-18B) configuration may result in less shortening, but it is
technically more difficult to obtain contact of bone surfaces.
Part or all of the medial and lateral malleoli can be removed to
increase contact of bone surfaces.
Make a 2- to 3-cm skin incision behind the medial malleolus,
and insert the first pin parallel to the plantar surface of the foot
and perpendicular to the longitudinal axis of the talus.
Ensure that the posterior tibial vessels and nerve are out of
harms way before inserting the pin. Use a pin sleeve to protect
the soft tissues.
Equal pin lengths should protrude from the medial and lateral
aspects of the foot, with the threaded middle third of the pin
centered in the bone (Fig. 3-18C).
Place the pin in good-quality bone and far enough away from
the remodeled surface of the talus to avoid being pulled out
during compression. Take care not to insert the pin in the
subtalar joint. Predrilling with a 2.7-mm drill may be necessary in
hard cortical bone. Also, if necessary, remove bone and cartilage
from the posterior aspect of the tibia and talus to make pin
insertion easier.

Fig. 3-17 Miniarthrotomy incisions. (Redrawn from Paremain


GD, Miller SD, Myerson MS: Ankle arthrodesis: results after the
miniarthrotomy technique, Foot Ankle Int 17:247, 1998.)

On the lateral aspect of the ankle, place the radiolucent pin


guide over the protruding part of the pin that has been inserted
into the posterior aspect of the talus by sliding the pin through
the small hole in the guides distal section (Fig. 3-18D).
Insert the second pin into one of the four holes in the anterior
section of the guide. Because of the anatomy of the talus, the
pin usually is inserted distal to the first pin (Fig. 3-18E).
The radiolucent pin guide can be rotated on the posterior pin
to permit the distal insertion of the pin (Fig. 3-18F).

Compression Arthrodesis of the Ankle


Using the Calandruccio II External Fixation
Device
TECHNIQUE 3-4contd
the anterior aspect of the subtalar and talonavicular
joints.

Remodel the surfaces of the tibia and talus to obtain maximal


bone contact when the foot is held in the position in which the
ankle is to be fused.
Excise only minimal bone from the talus to ensure that enough
bone stock is available for insertion of the talar pins. Also,
preserve as much of the blood supply of the talus as possible.
Remove bone, cartilage, and fibrous tissues down to bleeding
bony surfaces. Take care not to injure the structures behind the
medial malleolus, especially while the joint is distracted or if the
dissection becomes extracapsular.

After remodeling, the tibial and talar surfaces should be flat


with maximal contact when the foot is plantigrade.
Remove the cartilage on the medial aspect of the medial and
lateral malleoli (Fig. 3-18A).

Ch003-A03329.indd 176

After selecting the site for insertion of the second pin, insert a
pin sleeve and trocar through a small skin incision. Advance the
trocar to dimple the surface of the cortex of the talus. Use image
intensification to determine whether the tip of the trocar is in
the desired site. Remove the trocar, and insert the pin through
the sleeve, leaving the pin and the pin sleeve in the radiolucent
guide after pin insertion.
After both talar pins have been inserted, place a 3-mm
smooth pin through the plantar surface, the calcaneus, and the
talus and into the medullary canal of the tibia to help maintain
the desired position of the foot while inserting the tibial pins
(Fig. 3-18G).
Identify the center of the vertical axis of the tibia by palpation,
and mark the surface.
Because the anterior talar pin usually is inserted distal and
anterior to the posterior talar pin, it is necessary to adjust the
proximal section of the radiolucent pin guide so that it is aligned
with the central vertical axis of the tibia.
Rotate the knob on the talar component to move the tibial
component posteriorly or anteriorly to correct the tilt and provide
proper alignment (Fig. 3-18H).

5/31/2007 12:09:57 PM

G
I
H
Fig. 3-18 Tibiotalar arthrodesis with Calandruccio II device (see text). A, Tibial and talar
surfaces remodeled for maximal contact. B, Ball-and-socket configuration. C, Insertion of
posterior talar pin. D, Placement of radiolucent pin guide. E, Insertion of second pin distal to
fi rst pin. F, Radiolucent pin guide can be rotated on posterior pin to permit distal insertion
of second pin. G, Smooth pin can be placed through plantar surface, calcaneus, and talus into
medullary canal of tibia to help maintain position during insertion of tibial pins. H, Rotation
of knob on tibial component corrects tilt and provides proper alignment. I, In dense cortical
bone, tibial pins may require predrilling with 2.7-mm drill.
Continued

Ch003-A03329.indd 177

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178

Part II Arthrodesis

Tibial pin clamps

Talar pin clamps

Anterior

Posterior

Fig. 3-18, contd J, Assembly of device. K, Attachment of frame to pins. L, Partial tightening
of bolts. M, Position of device after fi nal tightening of bolts. (From Calandruccio R: The
Calandruccio II compression device: technique manual, Memphis, Tenn, 1996, Smith & Nephew.)

Compression Arthrodesis of the Ankle


Using the Calandruccio II External Fixation
Device
TECHNIQUE 3-4contd
The decision as to the level at which the pins are to be
inserted into the tibia depends on the quality of the underlying
skin, soft tissue, and bone.
To obtain clearance between the tibial pins so that the clamps
do not interfere with one another, place the tibial pins in
different clusters of holes.

Ch003-A03329.indd 178

Make small incisions in the skin at the insertion sites of the pin
sleeves and pins.
After insertion of the first pin into the tibia, the pin sleeve and
pin remain in the radiolucent pin guide.
If dense cortical bone is present, it may be necessary to
predrill each tibial pin with a 2.7-mm drill to decrease the
likelihood of necrosis of bone (Fig. 3-18I). Although image
intensification or radiographs probably are not necessary to
evaluate the position of the pins, they can be used without
having to remove the radiolucent guide pin.

5/31/2007 12:10:00 PM

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

surface of the counter of the patients shoe.

to allow wound closure and to accommodate postoperative


swelling.

Although a rare occurrence, the distal pin can penetrate the

Apply a short leg plaster splint or cast with the forefoot

fibula and interfere with maximal contact of the tibial and fibular
surfaces. If this occurs, excise the bone around the pin.

supported to prevent equinus.

Excise the malleolus because it may impinge on the upper

The cluster of holes into which the tibial pins are inserted
determines the length of the compression bolt. If the pin is
inserted through the most proximal cluster of holes, the 7-inch
bolt is used; in the middle cluster, a 5-inch bolt is used; and in
the distal cluster, a 4-inch bolt is used.

Assemble the four sections of the Calandruccio II compression


device as follows (Fig. 3-18J). Hold a bolt with an attached talar
and tibial clamp beside the pin it will be attached to and check
for appropriate size. The bolts attached to the two posterior talar
pin clamps and the two posterior tibial pin clamps should be the
same length, and the bolts attached to the two anterior talar pin
clamps and the two distal tibial pin clamps should be the same
length but shorter than the bolts that have been attached
posteriorly (Fig. 3-18K).
Remove the radiolucent pin guide and drill sleeves, and apply
the clamps. After applying all four clamp assemblies, partially
tighten the bolts using the T-handle wrench (Fig. 3-18L).
Carefully evaluate the foot at this time to avoid an equinus
position, posterior displacement of the tibia on the talus, and
varus or valgus of the hindfoot. Externally rotate the foot
approximately 10 degrees on the tibia. Image intensification can
be used to evaluate the position of the foot.
Before final tightening of the bolts, remove the pin in the
plantar aspect of the foot.
Partially tighten the set screws that prevent lateral
displacement of the clamps on the pins.
Although compressive force can be applied to effect slight
bowing of the pins, this may cause the pins to cut out if the
bone is osteoporotic. The adequacy of compression should be
determined by inspecting the interface between the tibia and
talus and by using anteroposterior and lateral image
intensification or radiographs.
After final tightening of the bolts, it should be possible to see
at least a quarter inch of the end of the bolt in the slot of the
posterior window of the posterior tibial clamp and the anterior
window of the anterior tibial clamp (Fig. 3-18M). If the end of
the bolt protrudes behind the end of the tibial clamp, replace it
with a shorter bolt.
Avoid tension on the skin to prevent skin necrosis and
secondary infection, especially in the area of insertion of the
anterior talar pin. If the skin around a pin is under tension, make
one or more small incisions adjacent to the pin. When
compression is complete, and proper alignment is confirmed,
securely tighten the set screws that fit the clamps to the bolts.

179

If changes in position of the talus on the tibia are required in


the immediate postoperative period, loosen the clamps, and
make any necessary adjustments with the patient under
anesthesia. Additional compression can be applied with the use
of the T-handle wrench.

AFTERTREATMENT

The patient should maintain a non


weight bearing status. At 10 to 14 days after surgery, the
sutures are removed, and the operative site is inspected for
infection. At 6 weeks, the cast is removed, and radiographs
are obtained to determine if the compression device can
be removed. If new bone formation is sufficient at the
interface between the tibia and talus, the device can be
removed with the patient under sedation. A short leg
walking cast is applied and is worn for 6 weeks. At that
time, the cast is removed, and radiographs are obtained. If
fusion is evident, a compressive wrap is applied, and the
patient is advised to increase weight bearing gradually, fi rst
with crutches and then a cane. If at 12 weeks there is insufficient evidence of fusion, a short leg cast is applied, and
the patient is instructed to bear weight as symptoms allow.
Continued pain, especially pain of increasing intensity on
weight bearing, with little or no radiographic evidence of
fusion suggests the possibility of pseudarthrosis.

Tibiotalar Arthrodesis with Narrowing


Osteotomies of the Malleoli
After tibiotalar arthrodesis, the malleoli may rub against
the shoe counter, and the cosmetic appearance of the ankle
may be unacceptable to some patients. To correct these
problems, Stewart and Harley designed an arthrodesis that
incorporates the features of compression arthrodesis, anteromedial and anterolateral approaches, and narrowing osteotomies of the malleoli for improved appearance and shoe
tolerance. In 28 such osteotomies reported by Stewart et
al., the rate of union was 93%, and the long-term results
were very good, with an average Mazur rating of 80.4.

TECHNIQUE 3-5

Stewart and Harley

Make an anteromedial incision 1 cm medial to the anterior


tibial crest and an anterolateral incision at the anterior border of
the fibula (Fig. 3-19A). Expose both malleoli subperiosteally.

Close the wounds in the standard fashion. Clearance

Next, elevate the soft tissues anteriorly, and expose the entire

between the device and the skin surface should be enough

anterior capsule of the ankle.

Ch003-A03329.indd 179

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180

Part II Arthrodesis

Fig. 3-19 Stewart and Harley technique for compression arthrodesis of the ankle. A, Anteromedial
and anterolateral incisions are illustrated by red
lines. B, A longitudinal wedge of bone is removed
from the inner third of the medial malleolus,
medial side of the tibia, and medial side of the
talar body. C, A longitudinal wedge of bone is
removed from the lateral side of the metaphysis
of the distal end of the tibia, lateral side of the
talar body, and medial two thirds of the fibula.
(Redrawn from Stewart MJ, Beeler TC, McConnell
JC: Compression arthrodesis of the ankle: evaluation
of a cosmetic modification, J Bone Joint Surg 65A:219,
1983.)

TECHNIQUE 3-5 Stewart and Harleycontd


Use an osteotome to remove a longitudinal wedge of bone
about 10 cm long and 1 to 1.5 cm wide from the medial tibia
including the inner third of the medial malleolus; also include the
medial side of the body of the talus (Fig. 3-19B).
Remove a similar wedge about 10 cm long consisting of
the lateral side of the distal tibia, the lateral side of the body
of the talus, and the medial two thirds of the fibula
(Fig. 3-19C).
Thoroughly denude the articular surfaces of the distal tibia and

Tibiotalar Arthrodesis with a Sliding Bone


Graft (Blair Technique)
Blair described a procedure that fuses the distal tibia to the
talar neck in situations in which the body of the talus has
been lost or is osteonecrotic. This method uses an anterior
tibial sliding graft, allows nearly normal appearance of the
foot with little shortening of the extremity, and permits
some flexion-extension motion of the foot on the leg.
Morris et al. modified the technique and used a transcalcaneotibial pin for 6 weeks to improve stability.

the dome of the talus, and shingle the raw surfaces.

Apply the Calandruccio clamp (see Fig. 3-2) with the foot in
correct alignment.
Cut the remaining parts of the malleoli transversely at their
proximal ends and create a greenstick fracture to enable them to
lie flush against the denuded surfaces of the tibia and talus.

Secure each malleolus to the tibia with screws.


Resect the distal tip of each malleolus so that it does not
project distal to the subtalar joint.
Fill any remaining voids around the arthrodesis with bone
chips taken from the resected portions of the malleoli.

Obtain radiographs to confirm the correct positioning of


the arthrodesis, and close the wounds over suction drainage
tubes.

TECHNIQUE 3-6 Blair; Morris et al.


Make an anterior longitudinal incision beginning 8 cm proximal
to the ankle and ending at the medial cuneiform (Fig. 3-20A).
Dissect the interval between the extensor hallucis longus and
extensor digitorum longus, and retract the neurovascular bundle
medially.
Incise the capsule and periosteum in line with the skin incision.
Remove the avascular talar body if present (Fig. 3-20B);
morcellize it if necessary. Do not damage the talar head or neck.
Using a power saw, cut a rectangular graft 5 cm 2.5 cm
from the anterior aspect of the distal tibia.
Make a transverse slot 2 cm deep in the superior aspect of the
talar neck, and slide the tibial graft into it (Fig. 3-20C).
Hold the foot in 0 degrees of dorsiflexion, 5 degrees of valgus,
and 10 degrees of external rotation, and fix the proximal part of
the graft to the tibia with a screw (Fig. 3-20D).

AFTERTREATMENT The sutures are removed at 10 to 14


days, and the external fi xation device is removed at 6 to 8
weeks. A short leg walking cast is worn until the fusion is
solid. An elastic stocking is worn for several weeks after
the cast is removed, and foot and toe exercises are carried
out.

Ch003-A03329.indd 180

Insert a Steinmann pin vertically through the calcaneus and 3


to 10 cm into the distal tibia for added stability.

Pack cancellous bone grafts around the fusion site.


Apply a long leg cast with the knee flexed 30 degrees.

5/31/2007 12:10:02 PM

181

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

but leave intact the main components of the superficial peroneal


nerve.

Locate the ankle joint with a hemostat or a scalpel.


Return to the proximal edge of the incision, and open the
fascia down to the anterior syndesmosis. Sever the anterior
tibiofibular ligament. Continue the incision over the fascia of the
extensor hallucis brevis and extensor digitorum brevis.
Incise the anterior talofibular ligament and what remains of
the joint capsule to expose the lateral aspect of the body of the
talus.

Raise the contents of the sinus tarsi in a full-thickness flap,


including all components of the inferior extensor retinaculum and
the cervical ligament and all the tendons of origin of the
extensor digitorum brevis and extensor hallucis brevis, to expose
the neck of the talus, the posterior facet, and the sinus tarsi.

Place a small, curved Hohmann retractor around the neck of


the talus anteriorly, and continue to incise the capsule out to the
talonavicular joint.

Fig. 3-20 Blair fusion. A, Approach to the ankle. B, Excision


of the body of the talus. C, Sliding bone graft. D, Graft in
its fi nal position. (Redrawn from Dennis MD, Tullos HS: Blair
tibiotalar arthrodesis for injuries to the talus, J Bone Joint Surg
62A:103, 1980.)

AFTERTREATMENT

At 6 weeks, the cast and Steinmann


pin are removed, and a short leg walking cast is applied;
this cast is worn until fusion is solid.
Tibiocalcaneal Arthrodesis

Tibiocalcaneal Arthrodesis with a


Calandruccio II External Fixation Device
TECHNIQUE 3-7
With the patient supine, place a lift under the ipsilateral
buttock. Prepare and drape the extremity using sterile technique.
Prepare the anterior ilium if a bone graft is needed.

Locate the ankle joint at its most lateral point and place a
hemostat or Freer elevator in the junction at the lateralmost
aspect of the ankle joint between the plafond and the fibula to
serve as a guide when the fibular malleolus is removed.
Expose the distal 5 or 6 cm of the fibula on the anterior and
lateral margins.
With a power saw or osteotome, section the fibula
approximately 3 cm proximal to the ankle joint, directing the
osteotomy from proximal lateral to distal medial in the direction
of the previously placed guide at the lateral border of the ankle
joint. The osteotomy should end approximately 1 cm proximal to
the tibial plafond.
Hold the proximal aspect of the fibula with bone-holding
forceps and sharply excise the entire distal fragment. Try to
protect the peroneal tendons. This allows better exposure of the
talus and sinus tarsi.
Morcellize the fibular malleolus for bone grafting.
Returning to the talus, locate the junction of the neck and the
body. Just distal to that junction drill several holes transversely
through the talar neck with a 3.2-mm bit, and transect the body
of the talus from the talar neck.

the fibula and 10 to 12 cm proximal to the distal tip of the


malleolus. Make the incision parallel to the fibula, and gently
curve it 2 cm distal to the tibiotalar joint across the sinus tarsi,
extending 6 to 8 cm distally from the apex of the curve. The
incision should be just through the skin because the superficial
peroneal nerve lies between the subcutaneous tissue and the
deep investing fascia of the lower leg.

The anatomy can be confusing in patients with posttraumatic


conditions or rheumatoid arthritis in whom severe subluxation or
dislocation of the subtalar joint has placed the calcaneus entirely
lateral to the talus; however, the calcaneocuboid joint and the
talonavicular joint usually can be located by placing a right-angle
retractor or a curved Hohmann retractor under the anterior flap.
When the talonavicular joint is identified, progressing proximally
to the body of the talus can help differentiate the talus from the
calcaneus even if the two have autofused.

Excise the most anterior branch of the superficial peroneal


nerve near the level of the ankle joint if needed for exposure,

Try to preserve as much of the calcaneus as possible when the


body of the talus is removed. If an osteotomy is needed and

Make an anterolateral incision, beginning 1 to 2 cm anterior to

Ch003-A03329.indd 181

5/31/2007 12:10:03 PM

182

Part II Arthrodesis

Tibiocalcaneal Arthrodesis with a


Calandruccio II External Fixation Device
TECHNIQUE 3-7contd
there is any concern about the junction of the talar body and the
posterior facet of the calcaneus, place two pins at right angles to
one another in an area that is suspicious, and obtain radiographs
at 90 degrees to one another to help locate the appropriate
osteotomy site between the talus and calcaneus.

When the talocalcaneal posterior facet is located, return to the


neck of the talus, and use an osteotome to osteotomize the neck
of the talus through the previously placed drill holes, which act
as a guide for the osteotomy.
When the osteotomy has been made, make a medial incision,
beginning 5 cm proximal to the tip of the medial malleolus and
just anterior to the medial border of the tibia so that it crosses
the ankle at the juncture of the tibial plafond and medial
malleolus. Curve the incision distally, traversing between the
anterior tibial and posterior tibial tendons. Extend the incision to
the tarsonavicular.

Identify and ligate the saphenous vein if it prevents exposure.


Identify the anteromedial aspect of the tibial plafond and
place a hemostat or Freer elevator at that point.

Raise the posterior flap of the incision approximately 1 cm.


This must be a full-thickness flap from the bone.

Use an osteotome or a power saw to remove the medial


malleolus obliquely, ending the osteotomy just medial to the
previously placed guide.
Excise the medial malleolus, protecting the posterior tibial
tendon, if intact, to expose the medial aspect of the body of the
talus, the talar neck, and the medial aspect of the talonavicular
joint.

Frequently, the articular surface of the head of the talus is


facing medially and plantarward with the navicular subluxed
laterally and superiorly.

Raise the anterior flap on bone so that the intervening island


of tissue carries the dorsalis pedis artery and deep peroneal
nerve and the tendons crossing the anterior aspect of the ankle.
Remove the talar body by placing an osteotome between the
body and neck fragment and levering the proximal fragment
(body of the talus) medially and laterally. Remove all soft tissue.
Place anterior traction on the talus by grasping the body of
the talus with a bone holder and plantar flexing the foot,
subluxing the talus anteriorly, and remove the posterior soft
tissue sharply or with an elevator.

If removing the body of the talus is difficult, section the talar


body in quadrants. Also, a right-angle retractor beneath the
anterior flap allows manual manipulation of the body through
the medial and the lateral incisions simultaneously.
If the talus is not avascular, morcellize it to use as a bone
graft.

Ch003-A03329.indd 182

Remove what remains of the tibial plafond down to cancellous


bone with a rongeur, osteotome, or power saw.
Prepare the posterior facet of the calcaneus for arthrodesis by
removing all cartilage and all subchondral bone from the
posterior facet, including the sustentaculum tali.
Prepare the floor of the sinus tarsi for arthrodesis by removing
cortical bone, extending medially toward the anterior facet. This
gives a larger surface area to improve fusion.
Place a large Steinmann pin through the anterior aspect of
the heel pad in the midline, exiting into the calcaneus at the
junction of the posterior facet and the sinus tarsi to allow slight
posterior translation of the calcaneus on the tibia. The pin
should enter the plafond in its midportion, in the mediolateral
and anteroposterior planes, and extend up the tibia for several
centimeters for temporary fixation. This pin does not control
rotation, but does control anteroposterior and mediolateral
translation.

Remove a thin slice of the cortical surface of the anterior


aspect of the distal tibia, just large enough to accommodate the
cancellous surface of the neck of the talus when the arthrodesis
site is in its final position.
FIXATION

The 4-mm or 5-mm diameter pins are threaded in the middle


third. Hold the foot on the leg temporarily with a Steinmann pin
(5/64 inch) drilled through the heel pad and across the calcaneus
into the medullary canal of the tibia.
Place the posterior pin first. Make a 1-cm stab wound through
the skin while pulling the posterior flap superiorly or anteriorly so
that during closure the pin does not prevent wound closure. The
incision should be just through the skin to avoid the sural nerve.
Spread a hemostat in the longitudinal axis of the calcaneus
down to bone.
Place a drill guide over the pin for soft-tissue protection, and
drill the pin transversely through the midsubstance of the
tuberosity, entering the calcaneus at the junction of the
tuberosity of the calcaneus with the posterior facet as it curves
plantarward to meet the tuberosity.
Penetrate the medial cortex gently, and palpate the soft tissue
medially for penetration of the pin.
When the location of the pin is identified, which should be
well plantar and posterior to the neurovascular bundle, make a
1-cm incision through skin only in the longitudinal axis of the
calcaneus, and spread repeatedly until bone is reached. Holding
the soft tissues apart with a hemostat or small right-angle
retractor, drill the pin through the medial flap. Be certain to lift
the medial flap anteriorly to place the stab wound in an area
that will not be under tension when the posterior flap is brought
superiorly and anteriorly.
Leave the pins exposed and at equal length on either side of
the calcaneus, placing the threads of the pins within the

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calcaneus. Depending on the size and the width of the


calcaneus, some of the threads medially or laterally may be
exposed external to the skin, which is of no consequence.

Using one of the triangular Calandruccio compression clamps


as a guide, place the second pin. When this guide is placed,
ensure that the set screws are facing up so that they can be
tightened easily.
Using the middle or anterior portals of the transverse limb of
this compression device, place a pin through that portal to the
skin edge and make a small incision. It is important that no
tension remains on the skin around the pins. The incision should
be two or three times wider than the pin.
Spread the soft tissue down to bone with an elevator or
hemostat, and use a soft-tissue protector to drill the pin from
lateral to medial.

Try to use the most anterior or distal portal in the transverse


arm if possible. The wider the distance is between the pins, the
more compression is possible.
Place the second pin into the calcaneus where the posterior
facet meets the sinus tarsi. If the pin is placed in the center of
the calcaneus at this location, its medial exit portal will be
plantar to the neurovascular bundle and to all the posteromedial
tendons, including the flexor hallucis longus.
Retract the soft tissue medially from around the pin, and drill
the pin to the same depth as the previously placed pin.
Place the lateral clamp first by sliding it over the pins through
the calcaneus. The clamps rest approximately 5 to 8 cm from the
skin edge in their final placement.
Before placing the proximal pins, determine the rotational
alignment of the arthrodesis site. With the Calandruccio II clamp,
dorsiflexion and plantar flexion are adjustable any time during
compression, and varus and valgus angulation can be changed to
a small degree by disproportionate compression medially or
laterally; however, neither medial and lateral translation nor
rotation can be changed to any significant degree. Consequently,
when the first proximal pin is inserted, place the foot in 10 to 15
degrees of external rotation, 8 to 10 degrees of valgus, and
neutral dorsiflexionplantar flexion before the pin crosses the
tibia.
Using the portals in the longitudinal limb of the triangular
device as guides, drill the most proximal pin first.
Place the pin through the portal and, as it reaches the skin,
incise the point of entry and spread the soft tissue down to bone
with a soft-tissue protector placed over the pin. Try to place this
pin 1 cm anterior to the anterior edge of the fibula.
Take care not to encroach on the superficial peroneal nerve
and also be careful not to place the pin too far anteriorly
because it would drill through mostly cortical bone and might
lead to a ring sequestrum because of necrosis of bone from the
heat of drilling only cortical bone.

Ch003-A03329.indd 183

The drill should have a definite feel as it penetrates the


lateral cortex of the tibia, easily passes through the medullary
canal, and meets with resistance when it reaches the medial
cortex of the tibia.
After the pin is through the medial cortex, palpate it, and
make an incision over its point. Spread all the soft tissue down
to bone. Take care to prevent soft tissue from catching in the
threads of the center portion of the pin.
Pass the second pin through the middle or distal portal, taking
the same soft-tissue precautions. Do not skive across the anterior
cortex of the tibia. If placement of the proximal pins is prevented
by impingement on the longitudinal Steinmann pin holding the
alignment, back the Steinmann pin sufficiently from proximal to
distal to get the first and second pins across.
Place the medial and lateral clamps and, using the Allen
wrench, secure the pins within the clamp to prevent the clamp
from sliding on the pins.
The set screws for the compression device are dome-shaped.
Loosen the set screws in a proximal direction to obtain adequate
room for manual compression. Compression with a socket
wrench follows later.
When the final position of the arthrodesis is determined,
manually distract the arthrodesis around the previously placed
Steinmann pin, and place bone graft throughout the articular
surface and sinus tarsi of the calcaneus and around the prepared
surface of the distal tibia. The malleoli are good sources of this
bone graft.
After the graft has been placed, manually compress the foot
on the tibia, and use a socket wrench distally in a four-quadrant
manner, beginning in the anterolateral quadrant with five or six
full turns or until the proximal pin begins to bend slightly. Go to
the posteromedial quadrant and tighten the compression screw
until the medial sides of the pins begin to bow slightly. The third
quadrant is anteromedial, and the fourth quadrant is posterolateral. When all four pins are bowing slightly, remove the
intramedullary Steinmann pin if it has not been removed already.
Continue to tighten the bolts until the compression under direct
observation is satisfactory. The pins should bow slightly to
moderately at the end of the final compression.
After satisfactory compression is obtained, manually tighten
the dome-shaped set bolts on the transverse bars to prevent any
loss of compression during the weeks required for fusion. Use
large pliers to tighten all four set bolts securely.
Ensure that the small Allen set screws are firmly on the pins.
Check the final position on the anteroposterior view with
radiograph or image intensification. It is difficult to see the joint
laterally, and an image intensifier allows slight rotation of the
metal bars, which obscure the straight lateral view. (The most
recent modification of the Calandruccio device allows
examination of the arthrodesis using anteroposterior and lateral
views.) Rotate the ankle internally and externally to evaluate
anteroposterior position.

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Part II Arthrodesis

Tibiocalcaneal Arthrodesis with a


Calandruccio II External Fixation Device
TECHNIQUE 3-7contd
Radiographically evaluate the position of the neck of the talus
on the anterior aspect of the tibia by a lateral view with the
image intensifier, if available. The head and neck of the talus can
be secured to the anterior aspect of the tibia with a screw or a
Steinmann pin. We prefer to make a small anteromedial incision
in the dorsal flap and place a pin through the dorsal lip of the
navicular bone into the head and neck of the talus and then into
the tibia to avoid plantar flexion of the midfoot and forefoot on
the hindfoot at the talonavicular joint.

are the same as described for compression arthrodesis. A


posterior approach can be used if wide exposure is necessary for
removal of total ankle components or in patients with
osteonecrosis of the talus or significant deformities that require
correction.

After the arthrodesis site is prepared, determine the position


by holding the patella straight up and placing the foot in
neutral dorsiflexionplantar flexion, 8 to 10 degrees of valgus at
the heel, and slight posterior displacement of the calcaneus on
the tibia. Hold the foot on the tibia in the proper position
(usually with folded towels across the plantar surface of the
midfoot).

Remove the tourniquet.

Place a guidewire through the heel pad in line with the center

Place drains medially and laterally, exiting near the junction of

of the tibia. This pin exits the calcaneus just anterior to the
posterior facet. Drive the pin into the center of the medullary
canal of the tibia under image intensification.

the middle and distal thirds of the tibia so that they can be
reached easily beneath the cast for removal. Secure the drains to
the skin with adhesive strips.

Lavage the wounds with an antibiotic solution, and close in


layers.

Apply a large, bulky soft dressing from the toes to just below
the knee, and apply a short leg cast or mediolateral and
posterior splints.

Stephenson et al. described a simple, reproducible method of


determining the correct entry site. In the sagittal plane, draw a
line from the second toe to the center of the heel; in the coronal
plane, draw a line at the junction of the anterior and middle
thirds of the heel pad (Fig. 3-21). The intersection of these lines
indicates the correct entry portal for the nail.

Check the position of the guide pin with image intensification


in the anteroposterior plane.

AFTERTREATMENT The leg is elevated on several pillows


for 24 hours. The drains are removed, and the patient
begins nonweight bearing ambulation the day after surgery
and may pivot on the unoperated leg the day of surgery to
a bedside commode if desired. The patient usually is discharged on the second or third day after surgery and is
encouraged to rest and elevate the extremity for 2 to 3
weeks. At 3 weeks, the cast is changed, but the compression
device is not altered. It is possible to retighten any bolts
necessary, however, if adjustments in an anteroposterior or
varus-valgus plane are needed. Another nonwalking cast is
applied over a soft dressing, and no weight bearing on the
operated extremity is allowed for another 3 to 4 weeks.
Between 6 and 8 weeks, the compression device and pins
are removed in the office with sterile technique. A large
battery-driven power drill is used along with large pin
cutters. With an explanation of the procedure and ethyl
chloride spray around the skin edges or a small amount of
lidocaine, this procedure is not as difficult on the patient
as it would seem. A short leg walking cast is worn for 6
to 8 weeks.

Tibiocalcaneal Arthrodesis with


Intramedullary Nailing
TECHNIQUE 3-8 Graves et al.
The position of the patient, medial and lateral skin incisions,
soft-tissue dissection, removal of the body of the talus, and
fixation of the head and neck of the talus to the anterior tibia

Ch003-A03329.indd 184

Ant.

Mid.
Post.

Fig. 3-21 Method for estimating insertion site for retrograde


intramedullary fi xation of tibiocalcaneal arthrodesis. A, Line
in sagittal plane from tip of second toe to center of heel. B,
Line can be drawn in coronal plane bisecting medial malleolus. Intersection of lines indicates correct entry portal for
nail. (From Stephenson KA, Kile TA, Graves SC: Foot Ankle
17:781, 1996.)

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Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

185

Drill a hole in the calcaneus through a tissue protector that


has been pushed all the way to the bony surface of the
calcaneus.
Place the guidewire in the center of the medullary canal of the
tibia on the anteroposterior and lateral planes, and place an 8to 9-mm reamer over the guide pin (Fig. 3-22A).
Ream the calcaneus and tibia in 1-mm increments. We usually
ream 1 mm wider than the nail (13 mm).
After the reaming is completed, load a ReVision (Smith &
Nephew, Memphis, Tenn) intramedullary straight ankle fusion nail
onto a guide. This nail is available in 11-mm, 12-mm, and 13-mm
diameters and 15-cm, 18-cm, and 21-cm lengths.

Place the drill guide sleeves through the drill guide on a back
table to ensure that they line up correctly with the holes in the
nail (Fig. 3-22B). It is essential that the drill pass concentrically
through the drill guide and the nail without impinging on the
borders of the nail.
Hold the ankle in the proper position, and place the nail over
the guidewire with the outrigger guide on the lateral surface of
the leg.
Position the nail in the calcaneus, and reevaluate the position
of the arthrodesis before driving the nail into the tibia. Evaluate
the position of the nail and the position of the arthrodesis using
image intensification. Ensure that the portals of the outrigger
guide rest just anterior to the fibula or else the anterior cortex of
the fibula will force the drill for the proximal screws slightly

Fig. 3-23 A and B, Posttraumatic arthritis after severely


comminuted ankle fracture treated with external fi xation. C
and D, After tibiocalcaneal fusion with intramedullary rod.

anteriorly, causing the outrigger portal to not be exactly


concentric with the designated portal of the nail.

Before final seating of the nail, place bone graft from the
morcellized malleoli in the arthrodesis and in the sinus tarsi area
of the calcaneus.
Impact the nail after the bone graft has been applied. The tip
of the nail should rest anywhere from slightly inside the cortex of
the calcaneus to approximately 1 cm outside the plantar surface
of the calcaneus (Fig. 3-23). Do not allow it to protrude so far
that it would impede ambulation.

Fig. 3-22 ReVision intramedullary nail can be used for


ankle or tibiocalcaneal fusion (see text). A, Reaming of
calcaneus (or talus) and tibia. B, Nail and drill sleeve in
place for insertion of locking screws. (Redrawn from Graves
SC, Kile TA, Lederman R, et al: ReVision nail: technique manual,
Memphis, Tenn, 1997, Smith & Nephew.)

Ch003-A03329.indd 185

With the body of the talus removed, two modifications of the


technique may be required: Because the calcaneus rests more
laterally in relation to the ankle joint than does the talus, it may
need to be translated medially 1 to 2 cm so that the lateral edge
of the prepared surface of the tibia has no bony apposition with
the calcaneus. Placing the pin in the calcaneus anywhere but in
the midline is difficult because of the contours of the plantar
surface of the calcaneus. Consequently, moving the pin medially
in the calcaneus and leaving it in its anatomical position is more
difficult than placing the pin in the plantar midline surface of the
calcaneus and translating the whole calcaneus slightly medially.

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Part II Arthrodesis

Tibiocalcaneal Arthrodesis with


Intramedullary Nailing
TECHNIQUE 3-8 Graves et al.contd
This is done easily with both malleoli removed. In severe
subluxations of the subtalar joint, the calcaneus is so far lateral
that the nail will purchase only the lateral third of the talus. In
this situation, a compression device probably is a better choice of
fixation.

If only one screw can be placed distally (because there is no


talar body), try to drill the hole with a 3.5-mm bit, then use a
5-mm screw to give better purchase in the cancellous bone of
the calcaneus. Try to place two self-tapping screws in the
calcaneus.
When the talus has been left intact, place one self-tapping
screw in the calcaneus and one in the talus in the following
manner. Begin on the calcaneal side of the arthrodesis, and place
the most distal screw near the plantar cortex of the calcaneus.

After the hole has been drilled through the calcaneus, exiting
on its medial cortex, remove the inside barrel of the doublebarrel soft-tissue guide.
Measure the length of the screw with a depth gauge. The
screws in the calcaneus usually are 40 to 50 mm long, but this
varies with the size of the calcaneus.

Ensure that the drill guide opposes the lateral surface of the
calcaneus; if it does not, a false reading of the length of the
screw results, with subsequent protrusion into the soft tissue.
After the screw has been seated, evaluate its length using
image intensification. Minor adjustments in rotation still can be
made at this time if necessary.
For the proximal screws, start at the 15-cm marker on the
outrigger guide, and place a drill through a drill sleeve in the
portal just distal to the 15-cm marker in the proximal portal of
the nail. The caution described in placing the partially threaded
pins for the compression device also is pertinent to the
placement of the screws.

Make an incision through the skin, spread the soft tissue down
to bone, and snug the drill guide up to the lateral side of the
tibial cortex.
Use an outrigger guide and drill sleeves to prevent drilling
through the anterior cortex. Place two screws proximal to the
arthrodesis through separate stab wounds laterally, taking care
not to injure the superficial peroneal nerve. The tibial screws
usually are 22 to 26 mm long.
Penetrate the medial cortex of the tibia with the screw, but do
not allow more than a few threads to exit because this irritates
the skin over the medial end of the screw (Fig. 3-24).
Deflate the tourniquet, and place drains as previously
described for the compression technique.

Wrap a bulky soft-tissue dressing from the toes to the upper


tibia, and apply a short leg cast.

Ch003-A03329.indd 186

B
A, Failed open reduction and internal fi xation in
patient with peripheral neuropathy. B, After fusion with
intramedullary nail.
Fig. 3-24

AFTERTREATMENT

Postoperative care is essentially the


same as after the compression arthrodesis. The short leg
cast is changed at 2 to 3 weeks, and weight bearing is not
allowed for 6 weeks. Weight bearing is allowed in a short
leg walking cast 6 to 8 weeks after surgery.

Posterior Arthrodesis of the Ankle and


Subtalar Joints
Posterior arthrodesis permits lengthening of the Achilles
tendon through the same incision and ankylosis of the
ankle and subtalar joints. The procedure also may be kept
extraarticular. This technique rarely is used, but may be
appropriate when current instrumentation and equipment
are unavailable.

5/31/2007 12:10:08 PM

TECHNIQUE 3-9 Campbell


Make a 7.5-cm longitudinal incision medial to and parallel
with the Achilles tendon over the posterior aspect of the
ankle.
Retract the flexor hallucis longus medially, and expose the
posterior capsule of the ankle and subtalar joints.
If the procedure is to be kept extraarticular, do not incise
the capsule. Otherwise, incise the capsule transversely, and
remove the most posterior portion of the talus and the
posterior portion of the articular surfaces of the ankle and
subtalar joints.
With an osteotome, turn large flaps of bone distally from the
posterior aspect of the tibia and proximally from the superior
aspect of the calcaneus, overlapping them successively (Fig.
3-25A).
Add additional bone from the ilium or bone bank if necessary
to make a large bony bridge across the ankle and subtalar joint
(Fig. 3-25B).

AFTERTREATMENT

The ankle is immobilized in a plaster


cast from the toes to well above the knee, the foot being
maintained at a right angle. To allow for swelling, a rectangular window is cut in the cast over the dorsum of the
foot and ankle; the cast is replaced and held loosely with
bandages. At 4 weeks after surgery, another snugly fitting
boot cast is applied; if the reaction has been mild, a walking
cast suffices. Weight bearing is cautiously resumed; full
weight bearing usually is delayed for 8 to 12 weeks after
surgery. Cast immobilization is continued until ankle and
subtalar joints have solidly fused. Posterior arthrodeses

usually require longer periods of immobilization than do


other techniques. The patient generally acquires an almost
normal gait, although walking on irregular surfaces may
be difficult.

KNEE
Arthrodesis of the knee was fi rst performed by Albert of
Vienna in 1878 for instability caused by poliomyelitis.
Hibbs performed arthrodesis on a tuberculous knee in
1911, and Key described arthrodesis of the knee with external fi xation in 1932. This approach was modified by
Charnley in 1948 and serves as the foundation for the
numerous approaches used in arthrodesis with external
fi xation. Intramedullary fi xation for arthrodesis of the knee
was fi rst described in 1948 by Chapchal, who introduced
a Kntscher nail through an anterior femoral window
across the knee and obtained solid fusion in 85% of patients.
Later, Brashear and Hill advised introducing the nail
through the greater trochanter to avoid fracture of the
femur at the cortical window. Knutson and Lidgren used
a long intramedullary nail extending from the greater trochanter to the distal tibia. Their original description is
similar to the technique currently used.

Indications and Results


With the success of total knee arthroplasty, knee arthrodesis seldom is performed as a primary operation and usually
is reserved for patients who are not candidates for total
knee replacement. Occasionally, arthrodesis may be more
appropriate than arthroplasty in a young patient with severe

Fig. 3-25 A, Posterior extraarticular arthrodesis of ankle and subtalar joints. B, Posterior
intraarticular arthrodesis of ankle and subtalar joints.

Ch003-A03329.indd 187

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188

Part II Arthrodesis

arthrosis because of the patients weight, occupation, or


activity level. Other possible indications for primary
arthrodesis include painful ankylosis after infection, tuberculosis, or trauma; severe deformity in paralytic conditions;
neuropathic arthropathy; and malignant or potentially
malignant lesions around the knee. The most frequent
indication for knee arthrodesis currently is salvage of a
failed total knee arthroplasty.
Most current series of knee arthrodesis report successful
fusion in 80% to 98% of patients. Overall, properly selected
patients are satisfied with a fused knee, especially with the
decrease in pain postoperatively. Some postoperative concerns are the attention patients attract in public, difficulty
riding public transportation, difficulty sitting in theaters
and stadiums, and difficulty getting up after a fall. Patients
should be counseled about these difficulties preoperatively.
Some patients may benefit psychologically from a trial of
preoperative long-leg immobilization (cast or brace) to
decide if they can manage with a fused knee. Harris et al.
compared function after amputation, arthrodesis, and
arthroplasty for tumors around the knee and found walking
speeds and efficiency to be similar after all three procedures. Patients with arthrodeses had the most stable limbs
and performed the most demanding physical work and
recreational activities, but they had difficulty sitting and
were more self-conscious about the limb than were patients
with arthroplasty.

Techniques
Numerous techniques have been described for knee
arthrodesis, and these can be categorized by the type of
fi xation used. The amount and quality of bone present are
important in determining appropriate fi xation and the need
for bone grafting. The selection of arthrodesis technique
also is based on the individual patient and the surgeons
experience.

Compression Arthrodesis with External


Fixation
Compression arthrodesis generally is indicated for knees
with minimal bone loss and broad cancellous surfaces
with adequate cortical bone to allow good bony apposition
and compression. Advantages of compression arthrodesis
include the application of good, stable compression across
the fusion site and the placement of fi xation proximal and
distal to an infected or neuropathic joint. Disadvantages
include external pin track problems, poor patient compliance, and the frequent need for early removal and cast
immobilization.
Charnley reported a 98.5% rate of fusion in 67 patients
with compression arthrodesis of the knee, and others have
reported similar results in primary arthrodesis of the knee

Ch003-A03329.indd 188

with external fi xation. Currently, instead of a single pin


above and below the knee, as with the Charnley clamp, a
variety of monolateral, bilateral, and ring multipin fi xators
are used, with fusion rates ranging from 31% to 100%.
Hessmann et al. reported 19 knee arthrodeses using an
anterior unilateral external fi xator, citing advantages of
stability, limited tissue damage, and high patient comfort.
Hak et al. found similar fusion rates with single-plane
(58%) and biplane (65%) external fi xation in 36 knee
arthrodeses, although complications were numerous with
both devices. They concluded that despite biomechanical
advances in external fi xator design, knee arthrodesis
remains difficult to achieve in patients who have had multiple previous procedures, a failed total knee arthroplasty,
or an infected total knee arthroplasty with significant bone
loss. Knutson et al. also reported successful compression
arthrodesis in only 52% of patients who had a failed minimally or partially constrained total knee arthroplasty and
in only 38% of patients with a failed hinged total knee
prosthesis. Brodersen et al. similarly reported only a 56%
rate of successful fusion using external fi xation in patients
with failed hinged total knee prostheses.
TECHNIQUE 3-10
When extensive exposure is necessary, use an anterior
longitudinal incision; otherwise, a transverse incision can be
used. For arthrodesis after total knee arthroplasty, approach the
knee through a midline incision or through previous scars when
appropriate.

Split the quadriceps and patellar tendons, and excise the


patella.
Detach the joint capsule from the tibia anteriorly, and divide
the collateral ligaments.
Flex the knee so that the capsule and quadriceps mechanism
fall posteriorly on each side.
Remove the synovium, and excise the menisci, cruciate
ligaments, and infrapatellar fat pad.
With a power saw, cut the superior surface of the tibia exactly
transverse to the long axis of the bone, and remove a wafer of
cartilage and bone 1 cm thick.
Remove an appropriately sized segment of bone from the
distal femur so that raw bony surfaces are apposed with the
knee in the desired position. We have found total knee
instruments useful in making these bone cuts.
If arthrodesis is performed after failed total knee arthroplasty,
do not remove more bone from the femur and tibia, but
thoroughly clean the surfaces and attempt to interdigitate
irregular surfaces to give the best possible contact.
Charnley recommended a position of almost complete
extension for cosmetic reasons; we prefer arthrodesis with the

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Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

189

Parallel
Triangular
(half pin)

Triangular
(full pin)

A
Fig. 3-26 External fi xator configurations for knee arthrodesis. A, Parallel; standard HoffmannVidal configuration. B, Triangular half-pin configuration. C, Triangular full-pin configuration
provides rigid multiplanar stability. (From Windsor RE: Knee arthrodesis. In Insall JN, ed: Surgery
of the knee, 2nd ed, New York, 1993, Churchill Livingstone.)

knee in 0 to 15 degrees of flexion, 5 to 8 degrees of valgus, and


10 degrees of external rotation.

Insert the appropriate pins for the compression device


(Charnley or Calandruccio clamp). Tighten the clamps so that a
compression load of 45 kg is attained.
Close and dress the wound. If a compression clamp is used, a
long leg cast incorporating the clamp is applied; if a more rigid
external fixator is used, the cast can be omitted.
The compression device is removed after 6 to 8 weeks, and
either a long leg or a cylinder cast is applied, and graduated
weight bearing is begun. The cast is worn until fusion is solid,
usually another 6 to 8 weeks.
If a multipin, biplanar fixator is used, place three parallel
transfixation pins through the distal femur and three through the
upper tibia (Fig. 3-26A); if bony surfaces are adequate, fixation
usually is sufficient. If anteroposterior instability is present, insert
additional half-pins above and below the knee at angles different
from the initial pins (Fig. 3-26B). Connect all pins to the frame,
and apply compression.

A triangular frame configuration also can be used, with 6.5mm half-pins placed at a 45-degree angle to the anteroposterior
and mediolateral planes (Fig. 3-26C). This configuration provides
rigid stability and is tolerated better by the patient.

AFTERTREATMENT

The triangular frame configuration


usually is rigid enough to allow early weight bearing and
should be left in place for 3 months. After removal of the

Ch003-A03329.indd 189

triangular frame, the patient is allowed protected weight


bearing with crutches until clinical and radiographic union
is noted.

Arthrodesis with Intramedullary


Rod Fixation
Intramedullary nailing techniques probably are most appropriate when extensive bone loss does not allow compression
to be exerted across broad areas of cancellous bone, such
as after tumor resection or failed total knee arthroplasty.
The advantages of intramedullary nailing are immediate
weight bearing, easier rehabilitation, absence of pin track
complications, and high fusion rate. Vlasak, Gearen, and
Petty compared the results of knee arthrodesis using external fi xation (13 knees) with intramedullary nail fi xation
(13 knees) and found a much higher union rate with intramedullary nail fi xation (100%) than with external fi xation
(38%). Disadvantages of intramedullary nail fi xation are
significant blood loss, more frequent major complications,
and difficulty in obtaining correct alignment.
Puranen et al. reported successful fusion in 32 (96%) of
33 patients undergoing knee arthrodesis with intramedullary fi xation. Four nails broke, but only one of these
resulted in nonunion. Ellingsen and Rand reported successful intramedullary arthrodesis in 16 (89%) of 18 knees
after failed total knee arthroplasty; attempts at external
fi xation arthrodesis had failed in 9 patients. They concluded that although this method for salvaging a failed total
knee arthroplasty is successful, it is technically demanding,

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Part II Arthrodesis

requires lengthy operative time (average 6 hours) and has


frequent complications (10 of 18 knees). Donley et al.
reported fusion in 17 (85%) of 20 patients in whom the
indications for intramedullary knee arthrodesis were
infected total knee arthroplasty and posttraumatic pain and
instability in patients too young for total knee arthroplasty.
A two-stage procedure was used for all patients with an
infected total knee arthroplasty. These authors also noted
the long operative time (average 4.1 hours), significant
blood loss (1574 mL), and frequent complications, but concluded that the high percentage of fusion and the ability
of most patients to bear full weight by the second postoperative week make this technique attractive in selected
patients. For 12 of the 20 nails, they used stainless steel
wire loops passed through the eye of the nail and through
a hole drilled in the greater trochanter to prevent proximal
migration of the nail.
In a multi-institutional study, Waldman et al. reported
successful fusion at an average of 6.3 months in 20 of 21
patients with failed, infected total knee replacements. A
modular titanium nail was used in an attempt to reduce
the frequency of nonunion and other complications. Before
fusion, antibiotic-impregnated cement spacers were placed
in 16 of the 21 patients, and all patients underwent a 6week course of intravenous antibiotics before arthrodesis
was considered. An anterior approach to the knee was used,
and the joint surfaces were extensively dbrided. The bony
surfaces were prepared, using a cutting guide for maximal
bony apposition, followed by sequential reaming of the
tibia and femur using flexible reamers. Nails extended 4 to
6 cm beyond the isthmus of their respective bones. Nails
are available in only one length, and appropriate length was
obtained by cutting nails with a diamond-tipped saw. The
femoral nail was inserted retrograde, and the tibial nail was
inserted antegrade. Titanium spacers were used if metaphyseal bone loss was extensive. The nail segments were joined
with a conical couple and were stabilized with locking
screws. The fusion site was bone grafted with autogenous
and allogenic bone. Immediate weight bearing was allowed.
The potential disadvantages of this technique are lack of
compression applied at the time of nailing and the inaccessibility of the nail in the event of recurrence of infection
(Fig. 3-27).
Resection arthrodesis with intercalary allografts fi xed
with intramedullary nails was used by Weiner et al. for
treatment of malignant or aggressive benign bone tumors
around the knee in 39 patients. Nonunion occurred in
seven patients, but healed in five of these after bone grafting, repeat internal fi xation, or replacement of the allograft.
Three patients eventually required above-knee amputation.
Rasmussen et al. reported successful fusion in 12 of 13
patients treated with an intramedullary nail and a vascularized fibular bone graft for treatment of large skeletal defects
caused by the resection of tumors around the knee. In light
of the previous good results of an intramedullary nail

Ch003-A03329.indd 190

Fig. 3-27 Anteroposterior (A) and lateral (B) radiographs of


same patient obtained 6 months after patient was treated
with Neff nail. Successful fusion of knee was achieved.
(From Waldman BJ, Mont MA, Payman KR, et al: Infected total
knee arthroplasty treated with arthrodesis using a modular nail,
Clin Orthop 367:230, 1999.)

without a vascularized fibula graft, however, they suggested


that this should be considered only when a massive loss of
bone has occurred after a failed constrained total knee
arthroplasty, failed arthrodesis, or tumor resection. Wolf et
al. used massive segmental autogenous grafts from the
femur, tibia, and fibula for resection arthrodesis in 40
patients with tumors around the knee. Despite a high
complication rate (52%), 85% of patients obtained supportfree ambulation, and 25 (78%) of 32 evaluated an average
of 17 years after surgery had satisfactory function.
Kntscher nails have been used most commonly for
knee arthrodesis; however, with advances in intramedullary nailing for long bone fractures, several companies now
have knee arthrodesis nails available or can custom make
knee arthrodesis nails similar to femoral or tibial nails.
These newer nails have the advantage of allowing proximal
and distal interlocking with screws. Cheng and Gross
described a short, locked intramedullary nail designed specifically for knee fusions, citing as advantages the avoidance
of a second incision required for insertion of long nails, the
bulkiness of double-plating techniques in the relatively
subcutaneous anterior knee area, and the difficulties of
prolonged external fi xation.
We have found intramedullary nail fi xation for knee
arthrodesis especially useful when bone loss is extensive, as
in infected total knee arthroplasty; in this situation, it often
is best to stage the arthrodesis, fi rst removing the implant
and polymethylmethacrylate, allowing the infection to
clear, and then performing the arthrodesis. Techniques are
described for insertion of a standard intramedullary nail

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Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

and an intramedullary nail that can be locked proximally


and distally for added stability and rotational control.

TECHNIQUE 3-11
Place a sandbag under the affected hip and extremity so that
the greater trochanter can be palpated. Prepare and drape the
entire limb, including the hemipelvis, so that the iliac crest,
greater trochanter, and knee are visible. A fluoroscopic table-top
study and image intensification are helpful.

Approach the knee through a previous incision, if present, or


through a straight anterior incision 10 to 12 cm proximal and
distal to the joint line.
Carry the dissection down to the quadriceps tendon and the
medial patellar retinaculum.

Elevate the soft tissue medially and laterally in flaps containing


skin, subcutaneous tissue, capsule, and periosteum.
Dbride the joint in the standard fashion.
Total knee alignment guides are helpful in resection of the
tibial and femoral surfaces. Minimal bone should be resected.

Insert the nail antegrade from the greater trochanter over the
guidewire.
Maintain compression at the arthrodesis site to prevent
distraction as the nail enters the tibia.
The nail should be bowed concave laterally to reconstitute the
normal valgus of the tibiofemoral angle and more nearly
approximate the normal axis of the lower extremity.
Drive the nail until it reaches the metaphysis of the distal tibia
(Fig. 3-28). Its tip should not end in the diaphyseal area because
this might cause stress concentration and pain or fracture of the
tibia.
Sink the nail beneath the tip of the greater trochanter to
prevent irritation of the abductor muscles.
Pack the patella and other autogenous iliac bone grafts
obtained in the standard fashion around the arthrodesis.
Insert suction drainage tubes at the hip and knee, and close
both incisions.

Apply a compressive dressing and a posterior plaster splint


from the groin to the toes.

Excise the patella; set it aside for use later as a bone graft if
necessary.

Make an incision 5- to 7-cm long proximal to the tip of the


greater trochanter.

AFTERTREATMENT

The drains are removed in 2 or 3


days, and walking with crutches with touch-down weight

Incise the gluteus maximus fascia, and split the muscle fibers
longitudinally.
Identify the trochanteric fossa, and open it with a curved awl.
Use a blunt tapered T-handled reamer to open the proximal
femoral canal and pass a ball-tipped guide down the canal to the
knee. Also use the T-handled reamer to open the tibial medullary
canal, and insert the ball-tipped guide into the canal and
advance it to the metaphyseal area of the distal tibia.
Ream the tibial medullary canal progressively; the amount of
reaming required usually is determined by preoperative
measurements of the tibia and femur in the anteroposterior and
lateral planes. In most situations, a 12- to 14-mm nail is used.
Ream the femur and tibia over the femoral guide pin in 1-mm
increments in an antegrade fashion until cortical bone is
encountered and then ream in 0.5-mm increments. Ream the
canals to accommodate at least a 12-mm nail.
Retract the guide pin past the knee.
If a Kntscher nail is used, overream the bones at least
0.5 mm. (If a Sampson nail is used, it is recommended that the
femur and the tibia be overreamed 2 mm. This nail probably
cannot be extracted easily after arthrodesis is achieved.)
The length of the nail should be determined before surgery
from standing anteroposterior and lateral full-length radiographs
of the lower extremity or with the aid of image intensification.

Ch003-A03329.indd 191

Fig. 3-28 Intramedullary fi xation of knee fusion with


Kntscher nail (see text).

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192

Part II Arthrodesis

bearing on the operated side is allowed. If adequate healing


is apparent after 6 weeks, progressive weight bearing is
allowed. Crutches are used until union is achieved clinically and radiographically (Figs. 3-29 and 3-30).
Arthrodesis with a locked intramedullary nail, such as
the Knee Fusion Nail (Smith & Nephew, Memphis, Tenn),
is especially appropriate after failed total knee arthroplasty
(Fig. 3-31). These nails are available in 65-cm, 70-cm, and
75-cm lengths and 11-mm and 12-mm diameters. Special,
smaller diameter, and stepped nails are available to match
each individual patients femoral and tibial anatomy. The
nail should extend from the tip of the greater trochanter
to within 2 to 6 cm from the plafond of the ankle. The
thickness of the femoral and tibial components and any
bone defects that will be resected should be subtracted from
the length measured on preoperative long leg radiographs
of the hip, knee, and ankle.

Fig. 3-30 Resection arthrodesis of knee for hemangioendothelioma. A, Before surgery. B, After resection and arthrodesis using intramedullary nail and Kirschner wire for
internal fi xation. Fusion is solid.

The technique described is for knee arthrodesis after


failed total knee arthroplasty. Modifications are necessary
for arthrodesis for other reasons.

TECHNIQUE 3-12
With the patient supine on a fluoroscopic operating table and
a sandbag under the ipsilateral pelvis, prepare and drape the
lower extremity to allow access from the greater trochanter to
the foot; the foot should be visible to help with rotational
alignment.
Begin an incision at the tip of the greater trochanter, and carry

it proximally about 5 cm.

Adduct and internally rotate the limb, and identify the greater
trochanter and piriform fossa on fluoroscopy.
To determine the correct entry portal for the nail, manually
insert a tip-threaded guide pin at the piriform fossa, placing the
pin in the midplane of the femur on anteroposterior and lateral
views.
Using a skin protector, ream over the guide pin with a 9-mm
cannulated reamer down to the level of the lesser trochanter.
Remove the guide pin and the reamer, and insert a ball-tip
guidewire down the medullary canal to just above the knee;
insert the smooth end of the guidewire, rather than the ball-tip
end. Leave this wire in place while the knee is being exposed.
Apply and inflate a sterile tourniquet.

A, Infected total knee arthroplasty. B, After


dbridement with antibiotic spacer. C, Early postoperative
radiograph. D, Solid arthrodesis of knee.
Fig. 3-29

Ch003-A03329.indd 192

Make an incision over the knee at approximately the same


location as the incision used for the total knee arthroplasty. Use
a medial parapatellar incision to enter the knee joint.

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Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

resection guides for total knee prostheses, resecting a minimal


amount of bone.

When the total knee components, cement, and debris have


been removed and any necessary proximal tibial and distal
femoral resection has been done, remove the tourniquet, insert a
ball-tip guidewire into the tibial canal down past the tibia
isthmus, and ream the femoral and tibial medullary canals from
the knee.
Ream both canals 1 to 2 mm larger than the nail diameter
selected; ream the intertrochanteric region to 13 mm.
Use fluoroscopy to confirm proper nail length.
Place a marker over the greater trochanter and over the distal
tibia where the tip of the nail should be driven, and measure the
distance with the tibia and femur apposed.
Remove the guidewires and insert a nail of the appropriate
length and diameter. Insert the nail so that the normal anterior
bow is internally rotated about 45 degrees; this position provides
some flexion and valgus to the limb.
Carefully drive the nail down the femoral shaft without using
excessive force. Watch for signs of impending incarceration or
fracture.
As the tip of the nail exits the femur, reduce the tibia on the
femur using the previously placed marker lines to determine

Fig. 3-31 Knee arthrodesis with intramedullary nail fi xation


after infected total knee arthroplasty.

Before removing the total knee components, place a long ruler


anteriorly over the distal femur and proximal tibia. Use an
osteotome or electrocautery to draw vertical lines superficially on
the anterior tibial and femoral shafts along the line of the ruler
(Fig. 3-32). These lines are used to determine rotational
alignment when inserting the nail, so ensure that they are not
removed with bone cuts or resection of tibial implants.

Using osteotomes and appropriate total knee instrumentation,


remove all total knee components. Curet and clean out all debris
and bone erosion, preserving as much bone as possible. If the
patella is in good condition, preserve it to be used as a bone
graft; otherwise, remove it.
If the distal femur and proximal tibia need to be recut to allow
good bony apposition, use standard intramedullary knee

Ch003-A03329.indd 193

Fig. 3-32 Knee arthrodesis with intramedullary nail fi xation


(see text). A long ruler is placed anteriorly over distal femur
and proximal tibia, and lines are drawn on bones to be used
for determining rotational alignment. (Redrawn from LaVelle
DG: Knee fusion nail: technique manual, Memphis, Tenn, 1997,
Smith & Nephew.)

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194

Part II Arthrodesis

TECHNIQUE 3-12contd

for difficult salvage cases, especially cases in which bone


loss may require segmental allografting.

correct rotational alignment; carefully drive the nail across the


knee into the proximal tibia. Sink the nail so that the proximal tip
of the nail is flush with the greater trochanter. The distal end of
the nail should lie distal to the tibial isthmus and proximal to the
ankle joint.

TECHNIQUE 3-13

Compress or fill any defects or gaps in the knee region. If


necessary, remove small segments of bone to improve medial
and lateral contact. If the knee is not actively infected, use bone
grafts to fill any gaps.

Develop the interval between the quadriceps tendon and the


vastus medialis muscle, and carry the dissection through the
periosteum of the femur (Fig. 3-33B).

Make a long medial parapatellar incision extending about


12.5 cm proximal and distal to the joint (Fig. 3-33A).

Insert proximal and distal locking screws as described for


subtrochanteric fractures (see Chapter 52); close the wounds in
the usual manner.

AFTERTREATMENT

The patient is instructed in hip


abduction and flexion exercises and ankle exercises. Touchdown weight bearing is allowed for 4 to 6 weeks, then
weight bearing is progressed as tolerated. If significant gaps
are noted at the knee at 6 to 12 weeks, the proximal or
distal locking screws are removed to dynamize the nail.
Additional bone grafting may be required if significant
defects are present. Nail removal usually is unnecessary.

Arthrodesis with Plate Fixation


In 1961, Lucas and Murray reported successful fusion in 17
of 18 knees with a method of knee arthrodesis in which
the knee joint is fi xed by two long plates placed at right
angles to each other, noting that Osgood reported a similar
procedure in 1913. In 1991, Nichols et al. reported the
successful use of dual dynamic compression plates to achieve
fusion in 11 patients. Although Lucas and Murray applied
one plate medially and the other anteriorly, Nichols et al.
placed the plates medially and laterally because they believed
this might prevent the difficulties with wound closure that
are sometimes encountered with an anterior plate. They
also suggested staggering the plates to reduce the risk of
fracture at the plate margin. Compared with external fi xation, the advantages of dual plate fi xation are that pin track
infection and pin loosening are avoided, and early weight
bearing can be allowed. They do not recommend dual
plate fi xation in grossly and acutely infected knees, but if
the infection seems to be low grade, a positive culture
result is not considered a contraindication to the use of the
dual plate method.
Stiehl and Hanel reported the use of combined intramedullary rod and medial compression plate fi xation in
eight arthrodeses, all of which united. Four of the arthrodeses were performed for failed total knee arthroplasty (three
of which were infected), two for chronic osteomyelitis, one
for Charcot neuropathy, and one for extensive bone loss
from a shotgun wound. They recommended this technique

Ch003-A03329.indd 194

Fig. 3-33 Lucas and Murray technique of knee arthrodesis.


A, Skin incision. B, Skin and subcutaneous tissue have been
reflected, exposing quadriceps tendon, patella, and patellar
tendon. C, Stripping subperiosteally, flaps have been raised
medially and laterally, exposing femur, tibia, knee joint, and
deep surface of patella. D, Femur and tibia have been fi xed
by two stainless steel plates, one applied medially and one
anteriorly. E, Dynamic compression plates placed medially
and laterally in staggered fashion. (AD Redrawn from Lucas
DB, Murray WR: Arthrodesis of the knee by double-plating, J
Bone Joint Surg 43A:795, 1961; E from Nichols SJ, Landon GC,
Tullos HS: Arthrodesis with dual plates after failed total knee
arthroplasty, J Bone Joint Surg 73A:1020, 1991.)

5/31/2007 12:10:15 PM

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

Incise the periosteum of the tibia; strip subperiosteally and


raise flaps of skin, subcutaneous tissue, muscle, periosteum, and
joint capsule, and retract them to expose the femur, tibia, knee
joint, and deep surface of the patella (Fig. 3-33C).

Excise the patella, and put it aside for use later.


Excise the menisci, cruciate ligaments, and any joint debris.
Cut the distal femur and proximal tibia with a saw to remove
all the articular cartilage. We have found total knee instruments
useful in making these bone cuts.

Place the femur and tibia in the desired position. The bones
can be temporarily fixed with a transfixing Steinmann pin.
Use a plate bender to contour two broad, 8-hole to 12-hole
AO plates to fit anteriorly and medially or laterally and medially.
Apply the plates and fix them with screws through both cortices
using standard AO plates to fit anteriorly and medially (Fig. 333D) or laterally and medially (Fig. 3-33E). It may be helpful to
use fully threaded cancellous screws in the metaphyseal areas.
Cut the patella into pieces, and pack them in any defects
around the joint margins or secure them to the arthrodesis site
with screws.

Close the wound in layers, and apply a long leg cast.


AFTERTREATMENT Partial weight bearing is begun as
tolerated and is progressed over 10 to 12 weeks. The cast
is worn until fusion is solid. The plates can be removed
after the fusion is mature.
Although knee fusion effectively relieves pain and provides stability in most patients, the awkwardness in sitting
and walking, along with the limited endurance and development of low back pain, prompts some patients to choose
total knee arthroplasty. In 1988, Holden and Jackson
reported good results with total knee arthroplasty in two
patients whose knees had been fused for 1 and 16 years,
respectively. Cameron and Hu, in 1996, reported total knee
arthroplasty after takedown of surgical knee fusions in 17
patients. Although 10 of the 17 had excellent or good
results, and all patients preferred the mobile knee, the frequency of complications (53%) tempered the authors
enthusiasm for this procedure. More recently, Kim et al.
compared the results of 16 total knee arthroplasties after
spontaneous ankylosis and 14 total knee arthroplasties after
takedown of femoral knee fusion. Improvements in Hospital
for Special Knee Surgery knee scores and ambulatory status
were similar in both groups, and all patients were satisfied
with their results. Total knee arthroplasty after knee fusion
is discussed in Chapter 6.

HIP
In 1894, Heusner of Germany reported the fi rst successful
arthrodesis of the hip in a patient with an old congenital

Ch003-A03329.indd 195

195

hip dislocation. A variety of techniques for hip arthrodesis


have been described subsequently. Early procedures were
intraarticular and required extensive postoperative immobilization, usually in a spica cast. Later Albee, Maragliano,
and others attempted extraarticular arthrodesis using iliofemoral bone grafts. Farkas decreased the frequency of
nonunion by adding a subtrochanteric osteotomy to prevent
direct transmission of movement of the long femoral lever
arm to the hip. Internal fi xation was introduced by WatsonJones and others in the 1930s. Charnley attempted to
increase stability by central displacement of the femoral
head into the medial pelvis, along with simultaneous internal compression with a screw placed cranial to the femoral
head. These early methods of internal fi xation were still
associated with high rates of incomplete union and prolonged external immobilization. In 1966, Schneider developed a cobra-head plate as a method to gain more stability
of the arthrodesis.

Indications and Results


Since the 1970s, the interest in hip fusion has diminished
considerably because of the early success of cementless total
hip arthroplasty, and it is now considered a salvage procedure. Long-term results in a young population with
cementless implants are still forthcoming, however, and
arthrodesis still should be considered an alternative in a
patient younger than 40 years of age with severe, usually
posttraumatic, arthritis and normal function of the lumbar
spine, contralateral hip, and ipsilateral knee. Before arthrodesis is considered, nonoperative treatment of arthritis, such
as the use of walking aids and antiinflammatory medication, should be considered, as should less invasive and
potentially less debilitating operative procedures, such as
subtrochanteric osteotomy.
An absolute contraindication to arthrodesis is active
sepsis of the hip; the infection should be rendered inactive
for 12 months before arthrodesis is undertaken. Relative
contraindications include severe degenerative changes in
the lumbosacral spine, contralateral hip, or ipsilateral knee.
Poor bone stock because of osteoporosis or iatrogenic
causes, such as proximal femoral resection for tumor, also
is associated with lower success rates and increased
disability.
The importance of careful patient selection cannot be
overemphasized. Hip fusion increases stress in the lumbar
spine, contralateral hip, and ipsilateral knee and requires
greater energy expenditure for ambulation; hip fusion
probably should be done only in young, otherwise healthy
patients. Properly selected patients generally are satisfied
with the results of hip fusion. Several long-term follow-up
studies have documented patient satisfaction of approximately 70% at 30 years despite evidence of degenerative
changes in the lumbar spine and adjacent joints of the lower
extremities, which typically manifest 15 to 25 years after

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196

Part II Arthrodesis

hip arthrodesis. Symptomatic changes in the lumbar spine


have been reported to occur in 55% to 100% of patients,
whereas similar problems with the ipsilateral and contralateral knee occur in 45% to 68% and in the contralateral
hip in 25% to 63%. Callaghan et al. and Sponseller et al.
noted that ipsilateral knee pain and contralateral hip pain
occur less frequently than low back pain, but more often
require operative intervention, usually total knee or hip
arthroplasty.
Roberts and Fetto reported patient satisfaction and good
or excellent functional results at an average 8.5-year followup in 10 patients with hip fusions. Barnhardt and Stiehl
reported, however, that only three of their six patients with
hip fusions would choose arthrodesis over total hip arthroplasty, citing complaints of low back pain, limited ambulation, and sexual dysfunction.

Techniques
Successful arthrodesis of the hip can be achieved through
a variety of methods. Regardless of the technique selected,
the hip should be fused in approximately 30 degrees of
flexion, 0 to 5 degrees of adduction, and 0 to 15 degrees
of external rotation.
Arthrodesis with Cancellous Screw Fixation
Benaroch et al. described a simple method of hip arthrodesis for adolescent patients. Through an anterolateral
approach, an anterior capsulotomy is performed, the femoral
head is dislocated, and both sides of the joint are denuded
of articular cartilage and necrotic bone. The leg is placed
in a position that allows maximal contact between the
femoral head and acetabulum, and one or two cancellous
screws are placed from the inner surface of the ilium to
engage the femoral head. Before tightening the screws to
compress the femoral head into the acetabulum, a subtrochanteric osteotomy is performed to decompress the long
lever arm of the femur. Fusion was obtained in 11 of the
13 patients (average age 15.6 years); 2 had mildly symptomatic nonunions. At an average 6.6-year follow-up, 9
patients had no pain or slight pain, 3 had mild pain, and
1 had marked pain. According to a modified Harris hip
scoring system, functional results were excellent in 5
patients, good in 2, fair in 5, and poor in 1. The investigators noted a progressive drift into adduction averaging 7
degrees, most of which occurred within 2 years of surgery;
because of this, they recommended fusion with the hip in
20 to 25 degrees of flexion and neutral or 1 to 2 degrees
of abduction.

Arthrodesis with a Muscle-Pedicle Bone


Graft
Davis described a technique in 1954 that included transfer
of a portion of the anterior ilium with the origins of the

Ch003-A03329.indd 196

tensor fascia lata and the anterior fibers of the gluteus


medius and gluteus minimus as a muscle-pedicle bone
graft. Although the original technique included an intertrochanteric osteotomy, we do not routinely include this.
A disadvantage of this technique is that it requires approximately 12 weeks of postoperative spica cast
immobilization.

TECHNIQUE 3-14

Davis

Begin an anterior iliofemoral incision (Technique 1-64) 7.5 cm


posterior to the anterior superior iliac spine, extend it along the
anterior crest of the ilium to the anterior superior spine, and
curve it distally and posteriorly to end near the base of the
greater trochanter (Fig. 3-34A).
Deepen the incision to the iliac crest, and identify the space
between the sartorius and tensor fasciae latae muscles. Detach
the sartorius muscle from its origin, and retract it out of the
wound.
By subperiosteal dissection, separate the aponeurosis of the
abdominal muscles and the iliacus minor from the superior and
medial surfaces of the ilium.

Direct an osteotome first in the longitudinal and then in the


lateral direction, and cut a graft of appropriate size from the
anterior crest. The graft is now free except for its muscle pedicle,
consisting of the tensor fasciae latae and the anterior fibers of
the gluteus medius and gluteus minimus muscles.
Develop the muscle pedicle by sharp dissection in the course
of the muscle fibers. Control bleeding by packing the donor area
and the graft with hot laparotomy sponges.
Detach the straight head of the rectus femoris muscle, open
the capsule, and dislocate the joint.
Perform a routine intraarticular arthrodesis and reduce the hip.
Make a slot in the ilium above the acetabulum and in the
anterior part of the head and neck of the femur to receive the
graft (Fig. 3-34B). Determine the location of the slot by placing
the graft over the area it is to cover.
Make an intertrochanteric osteotomy, place the graft in the
slot, and secure it with one screw in the ilium and one in the
neck of the femur (Fig. 3-34C).
At the osteotomy site, join the adjacent ends of the femur
loosely with a single, strong nonabsorbable suture.

Close the wound in layers.

We do not routinely perform an intertrochanteric osteotomy. We often place the wide free surface of the graft
on a flat bed prepared on the ilium and the femoral head
and neck and fi x the hip internally with several Knowles
pins.

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Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

Fig. 3-34 Arthrodesis of hip with muscle-pedicle bone graft. A, Osteotome is placed medial
to iliac crest in preparation for resecting graft. B, After acetabulum and femoral head have
been denuded, slot is made in ilium and femoral head and neck. C, Graft is fi xed to ilium and
femoral neck with screws. (Redrawn from Davis JB: The muscle-pedicle bone graft in hip fusion,
J Bone Joint Surg 36A:790, 1954.)

AFTERTREATMENT Davis immobilized the extremity


with skin traction, with the patient in a standard hospital
bed for 7 to 10 days. A double spica cast was then applied.
Immobilization was continued until radiographs indicated
solid fusion.

Arthrodesis with Cobra Plate Fixation


Since Schneiders development of the cobra-head plate for
hip arthrodesis, the technique has been modified to allow
restoration of abductor function if the fusion is later converted to a total hip arthroplasty. The technique includes
a medial displacement osteotomy of the acetabulum and
rigid internal fi xation with the cobra plate. Murrell and
Fitch reported successful fusion in eight young patients
(average age 17 years) with this technique. All eight patients
had diminished pain and significant improvements in function. A disadvantage of the technique is that it creates a
stress riser distally that may result in femoral fracture with
relatively minor trauma. Klemme et al. noted that all four
of their adolescent patients who developed pseudarthrosis
ranked at or above the 90th percentile for their age-determined weights. Fusion was successful in the other seven
patients in their report. These authors recommended alternative or supplementary stabilization methods in adolescents at or above the 90th percentile weight for age.
TECHNIQUE 3-15

Murrell and Fitch

Place the patient supine with a sandbag under the ipsilateral


buttock. Prepare and drape both lower extremities and anterior

Ch003-A03329.indd 197

superior iliac spines to allow access to both iliac crests and both
ankles.

Make a linear longitudinal midlateral incision along the femoral


diaphysis to a point 8 cm distal to the tip of the greater
trochanter (Fig. 3-35A).

Open the fascia lata in line with its fibers for the length of the
wound; identify and protect the sciatic nerve throughout the
procedure.

Maintain exposure with a self-retaining retractor. Incise the


origin of the vastus lateralis, and reflect it off the greater
trochanteric flair and the linea aspera for a distance of 6 cm.
Identify the anterior and posterior margins of the gluteus
medius.

Use an oscillating saw to make a greater trochanteric


osteotomy so that the proximal fragment includes the insertion
of the gluteus medius and minimus (Fig. 3-35B).
Elevate the hip abductors with the greater trochanteric
fragment, and hold them superiorly with two large Steinmann
pins hammered into the iliac wing (Fig. 3-35C).
Perform a superior hip capsulotomy.
Elevate the periosteum of the outer table of the iliac wing
superiorly to the retracting Steinmann pins, anteriorly to the
anterior superior iliac spine and the anterior inferior iliac spine,
and posteriorly to the sciatic notch.
Place one blunt Hohmann retractor in the sciatic notch
subperiosteally to protect the sciatic nerve and the superior
gluteal artery and one anterior to the iliopectineal eminence.

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198

Part II Arthrodesis

Fig. 3-35 Hip arthrodesis with cobra plate fi xation (see text). A, Longitudinal
midlateral incision. B, Osteotomy of greater trochanter. C, Transverse innominate osteotomy. D, Cobra plate contoured and attached with two screws for
application of compression force. E, Final fi xation of plate. F, Lateral view
of plate and reattachment of greater trochanter.

F
TECHNIQUE 3-15

Murrell and Fitchcontd

Make a transverse innominate osteotomy between the


iliopectineal eminence and the sciatic notch at the superior pole
of the acetabulum.

weight-bearing surface of the femoral head and from the


acetabulum.

Remove a corresponding 0.5-cm wafer of bone from the


superior pole of the femoral head.

Displace the distal hemipelvic fragment and the proximal


femur medially 100% of the thickness of the innominate bone
by placing a curved, blunt instrument in the osteotomy and
levering the distal hemipelvis 1 cm.

Make the iliac cut with an oscillating saw, and complete it


with an osteotome. Use osteotomes and curets to remove any
remaining cartilage and sclerotic cortical bone from the superior

Remove the sandbag and place a Steinmann pin into each of


the anterior superior iliac spines; use the pins and a long-limbed
protractor to determine adduction and abduction of the limb.

Ch003-A03329.indd 198

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199

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

Fig. 3-35, contd G, Hip fusion


with cobra plate. (C Redrawn from
Murrell GA, Fitch RD: Hip fusion in
young adults, using a medial displacement osteotomy and cobra plate, Clin
Orthop 300:147, 1994.)

G
Evaluate internal and external rotation by observing the patella
and the malleoli relative to the two vertical Steinmann pins.
Position the hip in 25 degrees of flexion, neutral internal and
external rotation, and neutral adduction and abduction.
Contour a nine-hole cobra plate, and secure the proximal
portion to the ilium with a 4.5-mm cortical screw.

Pack any remaining corticocancellous bone around the hip


joint, and obtain an anteroposterior pelvic radiograph to check
the position of the plate, screws, and hip joint (Fig. 3-35G).
Thoroughly irrigate the wound, and close the soft tissue in
layers over drains.
No postoperative immobilization is applied.

Test hip flexion with the Thomas test.


Distal to the plate, attach an AO tensioner to the lateral
femoral cortex with a single unicortical 4.5-mm cortical screw
(Fig. 3-35D).
Insert a screw in the most distal hole of the plate, hook the
tensioner to the plate, and apply compression force across the
hip joint to ensure good bony apposition.
Secure the plate to the lateral femur with 4.5-mm bicortical
screws in eight of the nine holes, and remove the tensioner.

Insert 4.5-mm cortical screws in the proximal plate, taking


care to protect the neurovascular structures on the inner table of
the pelvis.
Remove the retractors and the Steinmann pins holding the
greater trochanter, and drill a 4.5-mm hole in the center of the
proximal greater trochanteric fragment.
Drill and tap a 3.2-mm bicortical screw in the proximal femur
through the third or fourth hole of the cobra plate.
Reattach the greater trochanter with a 4.5-mm cortical screw
and washer (Fig. 3-35E and F).

Ch003-A03329.indd 199

AFTERTREATMENT

Ambulation with partial weight


bearing is encouraged on day 2 or 3 after surgery. Partial
weight bearing with two crutches is continued for 6
weeks.

Arthrodesis with Hip Compression Screw


Fixation
Pagnano and Cabanela described hip arthrodesis with a
sliding hip compression screw, supplemented by two or
three cancellous screws placed proximal to the hip screw.
They believe this technique best meets their criteria, as
follows: (1) minimizes or delays the appearance and severity of low back pain by ensuring that the hip is fused in
the proper position, (2) minimizes postoperative immobilization to speed recovery, (3) allows later conversion to
total hip arthroplasty if necessary, (4) preserves the abductor musculature without significantly altering the anatomy
of the hip, and (5) avoids the use of bulky internal fi xation
devices that might damage the abductor muscles.

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200

Part II Arthrodesis

TECHNIQUE 3-16

Pagnano and Cabanela

Position the patient supine on the fracture table, and make a


Watson-Jones approach to the hip (Technique 1-66).
After the fascia is incised, develop the interval between the
gluteus medius and the tensor fascia femoris.
Obtain proper hemostasis, and detach the anterior third of the
gluteus medius from the greater trochanter to improve access to
the hip joint.
Externally rotate the leg, and detach the reflected head of the
rectus femoris from the joint capsule.

Make an anterior capsulectomy, and take the leg off the foot
holder on the fracture table.

Dislocate the hip, and place the leg in a figure-four position. A


complete capsulectomy usually is necessary at this point to gain
access to the acetabulum.
After the femoral head is retracted out of the way, use curets
and reamers to remove all remaining cartilage and soft tissue,
and obtain a bleeding articular cancellous surface.
Clean the femoral head in the same manner, using femoral
head female reamers such as those used for surface replacement
procedures.

After both articular surfaces are reamed, reduce the femoral


head into the acetabulum, replace the foot in the foot holder,
and place the hip in the proper position for arthrodesis (30
degrees of flexion, neutral abduction and adduction, and slight
external rotation to match the opposite limb).
If needed, pack cancellous chips from the reamings or from
the iliac crest into the interstices between the femoral head and
the acetabulum.

Expose the lateral aspect of the proximal femur.


Drill a hole in the lateral femoral cortex 2.5 to 3 cm below the
abductor ridge and, using radiographic control, insert a guide pin
through the center of the femoral head and into the thick
supraacetabular area of the ilium. Usually an angle of 150
degrees is required.

reevaluated at 12 to 14 weeks, and if stable union is questionable, another minispica cast is applied or a removable
polypropylene orthosis is used for another 4 to 6 weeks.
Full recovery often takes 6 months, and patients may
require 12 months before returning to labor-intensive
occupations. Routine removal of the hardware is advisable
after 18 months to promote bone remodeling and make
later conversion to total hip arthroplasty easier.

Arthrodesis in the Absence of the Femoral


Head
In 1931, Abbott and Fischer designed a method for arthrodesis of the hip after infection with complete destruction
of the femoral head and neck. The procedure also has been
used after nonunion of the femoral neck, in patients with
osteonecrosis of the femoral head, after failed femoral head
prostheses, and in patients with infected trochanteric mold
arthroplasties. The operation is carried out in two or three
stages: (1) correction of the deformity (rarely necessary as
a separate stage), (2) arthrodesis of the hip in wide abduction, and (3) fi nal positioning by subtrochanteric
osteotomy.

TECHNIQUE 3-17

Abbott, Fischer, and Lucas

CORRECTION OF DEFORMITY

To correct severe deformity, first free the greater trochanter


from the wing of the ilium, then apply heavy traction to the
femur through a Steinmann pin that is inserted through the
distal femoral metaphysis.
Gradually bring the extremity into a position of wide
abduction, which brings the greater trochanter near the
acetabulum and permits apposition at the time of arthrodesis.
ARTHRODESIS OF THE HIP IN WIDE ABDUCTION

Expose the acetabulum and proximal femur using an anterior


iliofemoral approach (Technique 1-64).

Choose an appropriate compression screw and implant as

Excise the capsule anteriorly and superiorly.

described for treatment of hip fractures (see Chapter 52). Place


two or three cancellous screws proximal to the hip screw for
added stability.

Dbride the joint, removing all acetabular articular cartilage


down to healthy cancellous bone.

Close the wound in the usual manner, and apply a single hip

Deepen the roof of the acetabulum to permit better seating of


the greater trochanter.

spica cast.

Resect the remaining portion of the femoral neck at its base,


and strip the abductor tendons from the greater trochanter and
adjacent femoral shaft.
AFTERTREATMENT

Touch-down weight bearing is continued for 8 to 10 weeks. If radiographs show evidence of


bony healing, a minispica cast (with the knee free) is
applied, and partial weight bearing is progressed to full
weight bearing over the next 4 to 6 weeks. The fusion is

Ch003-A03329.indd 200

Denude the greater trochanter down to bleeding cancellous


bone.

Bring the extremity into wide abduction, forcing the greater


trochanter well into the prepared acetabular cavity.

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201

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

Pack any remaining space with autogenous iliac grafts.

SECOND STAGE

The degree of abduction varies with the individual: In some


patients, 45 degrees may be sufficient, whereas 70 to 90
degrees may be required in others for accurate fitting and good
apposition of the bony surfaces. The degree of abduction must
be sufficient, however, to place the apposed surfaces under firm
compression.

In hips without sinuses, the femoroischial transplantation can

Apply a spica cast from the nipple line to the toes on the
affected side and to the knee on the opposite side.
FINAL POSITIONING BY SUBTROCHANTERIC OSTEOTOMY

When the arthrodesis is solid, as affirmed by clinical and


radiographic examination, open the distal limb of the iliofemoral
approach, retract the rectus femoris medially, and incise the
periosteum of the femur in the interval between this muscle and
the vastus lateralis.

be carried out in one stage.

Expose the proximal femur using a lateral approach (Fig.


3-36A to C).
Divide the shaft just proximal to the level of the ischial
tuberosity so that a point is formed on the distal fragment
superomedially. One must exercise judgment in selecting the site
for osteotomy. If the osteotomy is high, length is gained, and
strong tension is placed on the musculature and fascia, forcing
the end of the femur into the prepared ischial defect.
Retract the femur, and expose the distal and lateral aspects of
the ischial tuberosity by blunt dissection (Fig. 3-36D to F).
After denuding a suitable place on the tuberosity of the
ischium, make a cleft in it with a large curet.

Ligate branches of the lateral femoral circumflex artery as


required.

Flex the hip to approximately 90 degrees, and place a large


bone skid in the ischial defect.

Using a transverse osteotomy 5 cm distal to the lesser


trochanter, cut the shaft three-fourths through and carefully
fracture the medial cortex.

Extend the thigh to about 30 degrees, and force the end of


the femur into the defect.

Adduct and displace the shaft of the femur slightly medially so


that the medial cortex of the proximal fragment fits into the
medullary cavity of the distal fragment. Usually no internal
fixation is necessary. Abbott and Lucas recommended a position
of 5 to 10 degrees of abduction, 35 degrees of flexion, and 10
degrees of external rotation.

AFTERTREATMENT

Apply a bilateral spica cast, and if


radiographs through the cast are satisfactory, the patient is
immobilized until the osteotomy is solid.

Arthrodesis of the Proximal Femur to the


Ischium
In 1942, Bosworth published a method for arthrodesis of
the proximal femur to the ischium to be used when the
femoral head is extremely diseased or absent.

The periosteum and fibrous tissue that originally covered the


denuded area of the ischium now surround the end of the
femoral shaft similar to the half of a cuff.

AFTERTREATMENT

A double spica cast is applied and is


worn until radiographs show that the arthrodesis is solid.

Arthrodesis with Cobra-Head Plate


Fixation after Failed Total Hip Arthroplasty
Kostuik and Alexander reported 14 successful fusions for
failed total hip arthroplasties using the cobra-head plate and
an anterior AO dynamic compression plate (Fig. 3-37).
TECHNIQUE 3-19

Kostuik and Alexander

Expose the hip through a lateral approach.


Remove the implants, and clear the acetabulum and femoral
neck so that bleeding cancellous bone is exposed.
Reflect the hip abductors cephalad, exposing the ilium superior

TECHNIQUE 3-18

Bosworth

FIRST STAGE

If sinuses are present, a preliminary operation may be


necessary to remove the diseased trochanteric portion of the
femur, remnants of the neck, fibrous tissue, and granulation
tissue.

The wound is closed at the discretion of the surgeon, and


prophylactic antibiotic coverage is instituted.

Ch003-A03329.indd 201

to the acetabulum.

Place the femoral neck into the acetabulum, and apply a cobra
plate to the pelvis and femur, maintaining 5 to 10 degrees of
abduction, neutral rotation, and 15 degrees of flexion.
A pelvic osteotomy, as recommended by the AO group, is
done if necessary to attain proper placement of the femur.
Slight abduction, in contrast to the usual position of
adduction, is used to overcome leg length discrepancy caused by
the loss of the femoral head.

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202

Part II Arthrodesis

Fig. 3-36 Bosworth femoroischial transplantation. A, Lateral incision. B, Femur is exposed


subperiosteally and divided obliquely. Osteotome is angled proximally and medially. C, Fragments
are retracted for exposure of ischium. D, Location of ischium by palpation. Bony defect is
created in lateral surface of ischial tuberosity. E, Pointed end of femoral shaft is buried in
ischial defect. F, Proximal fragment has been removed for illustrative purposes, but may be left
in place. (Redrawn from Bosworth DM: Femoro-ischial transplantation, J Bone Joint Surg 24:38,
1942.)

TECHNIQUE 3-19 Kostuik and Alexandercontd


After plate fixation, place cancellous iliac grafts around the
arthrodesis.
Fix the greater trochanter to the site of the arthrodesis with a
cancellous screw.
Add a dynamic AO compression plate anteriorly on the
femoral shaft, and contour it to the ilium.
Close the wound over suction drainage tubes.

AFTERTREATMENT

A single spica cast is applied 1 week


after surgery and is worn until radiographs show a solid
arthrodesis.

Ch003-A03329.indd 202

Total Hip Arthroplasty after


Hip Arthrodesis
Conversion of a hip arthrodesis to total hip arthroplasty
most often is indicated for pain or generalized loss of function from immobility or malposition. This is a technically
demanding procedure, complications and failures are frequent, and improvement of function is uncertain. Reikers
et al. found that their best results were obtained in patients
who were young when they underwent fusion of the hip
and who had had the hip fusion for a relatively short time.
Of their 46 patients, none of whom had used crutches
before conversion to total hip arthroplasty, 10 used two
crutches and 24 used one crutch after total hip arthroplasty.
Most patients were satisfied, however, with their improved
mobility, maneuverability, and sitting ability. Kreder et al.

5/31/2007 12:10:21 PM

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

203

Charnley J: Osteoarthritis of the hip, Lancet 1:296, 1951.


Charnley J: Compression arthrodesis, Edinburgh, 1953, E & S
Livingstone.
Putti V: Arthrodesis for tuberculosis of the knee and of the
shoulder, Chir Organi Mov 18:217, 1933.

Fig. 3-37 Salvage of failed total hip arthroplasty with hip


fusion using cobra-head plate and dynamic AO compression
plate. (From Kostuik J, Alexander D: Arthrodesis for failed hip
arthroplasty, Clin Orthop 188:173, 1984.)

reported a 10% infection rate, a 10% revision rate, and a


5% resection arthroplasty rate because of infection in 40
hip replacements done after hip fusions. Rittmeister et al.
studied 18 patients with long-standing hip arthrodeses
(average 33 years) who had total knee arthroplasty, total
hip arthroplasty, or both. Their fi ndings suggested that
total knee arthroplasty alone is unlikely to provide satisfactory results in patients with hip fusions. They recommended total hip arthroplasty followed by total knee
arthroplasty even if severe osteoarthritis of the knee is the
main complaint. Total hip arthroplasty after arthrodesis is
discussed in detail in Chapter 7.

References
General
Brittain HA: Architectural principles in arthrodesis, 2nd ed, Edinburgh,
1952, E & S Livingstone.

Ch003-A03329.indd 203

Ankle
Abdo RV, Wasilewski SA: Ankle arthrodesis: a long-term study,
Foot Ankle 13:307, 1992.
Ahlberg A, Henricson AS: Late results of ankle fusion, Acta
Orthop Scand 52:103, 1981.
Albert E: Einige Flle Kunstilicher Anklyosen Bildung an
Paralytischen Gliedmassen, Wien Med Press, 1882.
Alvarez RG, Barbour TM, Perkins TD: Tibiocalcaneal arthrodesis for nonbraceable neuropathic ankle deformity, Foot Ankle
15:354, 1994.
Baciu CC, Filibiu E: Rapid arthrodesis of the ankle joint via
verticalisation of the joint space, Arch Orthop Trauma Surg
93:261, 1979.
Berman AT, Bosacco SJ, Parks BG, et al: Compression arthrodesis of the ankle by triangular external fi xation: biomechanical and clinical evaluation, Orthopedics 22:1129, 1999.
Berman AT, Bosacco SJ, Yanicko DR Jr, et al: Compression
arthrodesis of the ankle by triangular external fi xation: an
improved technique, Orthopedics 12:1327, 1989.
Bishop AT, Wood MB, Sheetz KK: Arthrodesis of the ankle with
a free vascularized autogenous bone graft: reconstruction of
segmental loss of bone secondary to osteomyelitis, tumor, or
trauma, J Bone Joint Surg 77A:1867, 1995.
Blair HC: Comminuted fractures and fracture dislocations of the
body of the astragalus: operative treatment, Am J Surg 59:37,
1943.
Braly WG, Baker JK, Tullos HS: Arthrodesis of the ankle with
lateral plating, Foot Ankle 15:649, 1994.
Buck P, Morrey BF, Chao EYS: The optimum position of
arthrodesis of the ankle: a gait study of the knee and ankle, J
Bone Joint Surg 69A:1052, 1987.
Cameron SE, Ullrich P: Arthroscopic arthrodesis of the ankle
joint, Arthroscopy 16:21, 2000.
Campbell CJ, Rinehart WT, Kalenak A: Arthrodesis of the
ankle: deep autogenous inlay grafts with maximum cancellous
bone apposition, J Bone Joint Surg 56A:63, 1974.
Campbell P: Arthrodesis of the ankle with modified distractioncompression and bone grafting, J Bone Joint Surg 72A:552,
1990.
Campbell WC: An operation for the induction of osseous fusion
in the ankle joint, Am J Surg 6:588, 1929.
Carrier DA, Harris CM: Ankle arthrodesis with vertical
Steinmann pins in rheumatoid arthritis, Clin Orthop Relat Res
268:10, 1991.
Casadei R, Ruggieri P, Giuseppe T, et al: Ankle resection
arthrodesis in patient with bone tumors, Foot Ankle 15:242,
1994.
Charnley J: Compression arthrodesis of the ankle and shoulder,
J Bone Joint Surg 33B:180, 1951.
Chuinard EG, Peterson RE: Distraction-compression bone graft
arthrodesis of the ankle: a method especially applicable in
children, J Bone Joint Surg 45A:481, 1963.
Cierny G III, Cook WG, Mader JT: Ankle arthrodesis in the
presence of ongoing sepsis: indications, methods, and results,
Orthop Clin North Am 20:709, 1989.
Cobb TK, Gabrielsen TA, Campbell DC, et al: Cigarette smoking
and nonunion after ankle arthrodesis, Foot Ankle 15:64,
1994.
Corso SJ, Zimmer TJ: Technique and clinical evaluation of
arthroscopic ankle arthrodesis, Arthroscopy 11:585, 1995.

5/31/2007 12:10:23 PM

204

Part II Arthrodesis

Cracchiolo A III, Cimino WR, Lian G: Arthrodesis of the ankle


in patients who have rheumatoid arthritis, J Bone Joint Surg
74A:903, 1992.
Crosby LA, Yee TC, Formanek TS, et al: Complications following arthroscopic ankle arthrodesis, Foot Ankle 17:340,
1996.
Danziger MB, Abdo RV, Decker JE: Distal tibia bone graft
for arthrodesis of the foot and ankle, Foot Ankle 16:187,
1995.
Davis RJ, Mills MB: Ankle arthrodesis in the management of
traumatic ankle arthrosis: a long-term retrospective study, J
Trauma 20:674, 1980.
Dennis DA, Clayton ML, Wong DA, et al: Internal fi xation
compression arthrodesis of the ankle, Clin Orthop Relat Res
253:212, 1990.
Dennis MD, Tullos HS: Blair tibiotalar arthrodesis for injuries
to the talus, J Bone Joint Surg 62A:103, 1980.
Dent CM, Patil M, Fairclough JA: Arthroscopic ankle arthrodesis, J Bone Joint Surg 75B:830, 1993.
DeVriese L, Dereymaeker G, Fabry G: Arthroscopic ankle
arthrodesis: preliminary report, Acta Orthop Belg 60:389,
1994.
Dohm MP, Benjamin JM, Harrison J, et al: A biomechanical
evaluation of three forms of internal fi xation used in ankle
arthrodesis, Foot Ankle 15:297, 1994.
Flock TJ, Ishikawa S, Hecht PJ, et al: Heel anatomy for retrograde tibiotalocalcaneal roddings: a roentgenographic and anatomic analysis, Foot Ankle 18:233, 1997.
Frey C, Halikus NM, VuRose T, et al: A review of ankle
arthrodesis: predisposing factors to nonunion, Foot Ankle
15:581, 1994.
Friedman RL, Glisson RR, Nunley JA II: A biomechanical
comparative analysis of two techniques for tibiotalar arthrodesis, Foot Ankle 15:301, 1994.
Fujimori J, Yoshino S, Koiwa M, et al: Ankle arthrodesis in
rheumatoid arthritis using an intramedullary nail with fi ns,
Foot Ankle Int 20:485, 1999.
Glick JM, Morgan CD, Myerson MS, et al: Ankle arthrodesis
using an arthroscopic method: long-term follow-up of 34
cases, Arthroscopy 12:428, 1996.
Goldthwait JE: An operation for the stiffening of the ankle
joint in infantile paralysis, Am J Orthop Surg 5:271,
19071908.
Graves SC, Kile TA, Lederman R, et al: ReVision nail: technique
manual, Memphis, Tenn, 1996, Smith & Nephew.
Gruen GS, Mears DC: Arthrodesis of the ankle and subtalar
joints, Clin Orthop Relat Res 268:15, 1991.
Hammerschlag WA: Ankle arthrodesis using a ring external
fi xator, Tech Orthop 11:263, 1996.
Hayes AG, Nadkarni JB: Extensile posterior approach to the
ankle, J Bone Joint Surg 78B:468, 1996.
Hefti FL, Baumann JU, Morscher EW: Ankle joint fusion: determination of optimal position by gait analysis, Arch Orthop
Trauma Surg 96:187, 1980.
Helm R: The results of ankle arthrodesis, J Bone Joint Surg
72B:141, 1990.
Holt ES, Hansen ST, Mayo KA, et al: Ankle arthrodesis using
internal screw fi xation, Clin Orthop Relat Res 268:21, 1991.
Hone MR: Dowel fusion of the ankle joint (proceedings), J Bone
Joint Surg 50B:678, 1968.
Iwata H, Yasuhara N, Kawashima K, et al: Arthrodesis of the
ankle joint with rheumatoid arthritis: experience with the
transfibular approach, Clin Orthop Relat Res 153:189 1980.
Johnson EE, Weltmer J, Lian GJ, et al: Ilizarov ankle arthrodesis,
Clin Orthop Relat Res 280:160, 1992.

Ch003-A03329.indd 204

Kile TA, Donnelly RE, Gehrek JC, et al: Tibiotalocalcaneal


arthrodesis with an intramedullary device, Foot Ankle 15:669,
1994.
King HA, Watkins TB Jr, Samuelson KM: Analysis of foot position in ankle arthrodesis and its influence on gait, Foot Ankle
1:44, 1980.
Kish G, Eberhart R, King T, et al: Ankle arthrodesis: placement
of cannulated screws, Foot Ankle 14:223, 1993.
Kitaoka HB: Salvage of nonunion following ankle arthrodesis
for failed total ankle arthroplasty, Clin Orthop Relat Res 268:37,
1991.
Kitaoka HB, Anderson PJ, Morrey BF: Revision of ankle
arthrodesis with external fi xation for nonunion, J Bone Joint
Surg 74A:1191, 1992.
Kitaoka HB, Romness DW: Arthrodesis for failed ankle arthroplasty, J Arthroplasty 7:277, 1992.
Lionberger DR, Bishop JO, Tullos HS: The modified Blair
fusion, Foot Ankle 3:60, 1982.
Lynch AF, Bourne RB, Rorabeck CH: The long-term results of
ankle arthrodesis, J Bone Joint Surg 70B:113, 1988.
Malarkey RF, Binski JC: Ankle arthrodesis with the Calandruccio
frame and bimalleolar onlay grafting, Clin Orthop Relat Res
268:44, 1991.
Mann RA, Van Manen JW, Wapner K, et al: Ankle fusion, Clin
Orthop Relat Res 268:49, 1991.
Marcus RE, Balourdas GM, Heiple KG: Ankle arthrodesis by
chevron fusion with internal fi xation and bone grafting, J Bone
Joint Surg 65A:833, 1983.
Maurer RC, Cimino WR, Cox CV, et al: Transarticular crossscrew fi xation: a technique of ankle arthrodesis, Clin Orthop
Relat Res 268:56, 1991.
Mazur JM, Cummings RJ, McCluskey WP, et al: Ankle arthrodesis in children, Clin Orthop Relat Res 268:65, 1991.
Mazur JM, Schwartz E, Simon SR: Ankle arthrodesis: long-term
follow-up with gait analysis, J Bone Joint Surg 61A:964, 1979.
McGuire MR, Kyle RF, Gustilo RB, et al: Comparative analysis
of ankle arthroplasty versus ankle arthrodesis, Clin Orthop Relat
Res 226:174, 1988.
Mears DC, Gordon RG, Kann SE, et al: Ankle arthrodesis with
an anterior tension plate, Clin Orthop Relat Res 268:70, 1991.
Miller SD, Paremain GP, Myerson MS: The miniarthrotomy
technique of ankle arthrodesis: a cadaver study of operative
vascular compromise and early clinical results, Orthopedics
19:425, 1996.
Moeckel BH, Patterson BM, Inglis AE, et al: Ankle arthrodesis:
a comparison of internal and external fi xation, Clin Orthop
Relat Res 268:78, 1991.
Monroe MT, Beals TC, Manoli A: Clinical outcome of arthrodesis of the ankle using rigid internal fi xation with cancellous
screws, Foot Ankle 20:227, 1999.
Moore TJ, Prince R, Pochatko D, et al: Retrograde intramedullary nailing for ankle arthrodesis, Foot Ankle 16:443, 1995.
Moran CG, Pinder IM, Smith SR: Ankle arthrodesis in rheumatoid arthritis: 30 cases followed for 5 years, Acta Orthop Scand
62:538, 1991.
Morrey BF, Wiedeman GP Jr: Complications and long-term
results of ankle arthrodesis following trauma, J Bone Joint Surg
62A:777, 1980.
Morris HD, Hand WW, Dunn AW: The modified Blair fusion
for fractures of the talus, J Bone Joint Surg 53A:1289, 1971.
Myerson MS, Allon SM: Arthroscopic ankle arthrodesis, Contemp
Orthop 19:21, 1989.
Myerson MS, Quill G: Ankle arthrodesis: a comparison of an
arthroscopic and an open method of treatment, Clin Orthop
Relat Res 268:84, 1991.

5/31/2007 12:10:24 PM

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

OBrien TS, Hart TS, Shereff MJ, et al: Open versus arthroscopic
ankle arthrodesis: a comparative study, Foot Ankle Int 20:368,
1999.
Ogilvie-Harris DJ, Fitsialos D, Hedman TP: Arthrodesis of the
ankle: a comparison of two versus three screw fi xation in a
crossed configuration, Clin Orthop Relat Res 304:195, 1994.
Ogilvie-Harris DJ, Lieberman I, Fitsialos D: Arthroscopically
assisted arthrodesis for osteoarthritis ankles, J Bone Joint Surg
75A:1167, 1993.
Ottolenghi CE, Animoso J, Burgo PH: Percutaneous arthrodesis
of the ankle joint, Clin Orthop Relat Res 68:72, 1970.
Ouzounian TJ: Ankle arthrodesis, Tech Orthop 11:255, 1996.
Paremain GP, Miller SD, Myerson MS: Ankle arthrodesis:
results after miniarthrotomy technique, Foot Ankle 17:247,
1996.
Pochatko DJ, Smith JW, Phillips RA, et al: Anatomic structures
at risk: combined subtalar and ankle arthrodesis with a retrograde intramedullary rod, Foot Ankle 16:542, 1995.
Pridie KH: Arthrodesis of the ankle, J Bone Joint Surg 35B:152,
1953.
Quill GE Jr: Tibiotalocalcaneal arthrodesis, Tech Orthop 11:269,
1996.
Rowan R, Davey KJ: Ankle arthrodesis using an anterior AO T
plate, J Bone Joint Surg 81B:113, 1999.
Russotti GM, Johnson KA, Cass JR: Tibiotalocalcaneal arthrodesis for arthritis and deformity of the hind part of the foot, J
Bone Joint Surg 70A:1304, 1988.
Schaap EJ, Huy J, Tonino AJ: Long-term results of arthrodesis
of the ankle, Int Orthop 14:9, 1990.
Schneider JM, Bono JV, Jacobs RL: Ankle arthrodesis: technique
tips, J Orthop Tech 2:5, 1994.
Scranton PE Jr: Use of internal compression in arthrodesis of the
ankle, J Bone Joint Surg 67A:550, 1985.
Scranton PE Jr: An overview of ankle arthrodesis, Clin Orthop
Relat Res 268:96, 1991.
Smith EJ, Wood PL: Ankle arthrodesis in the rheumatoid patient,
Foot Ankle 10:252, 1990.
Sonnabend DH, Duckworth D: A new technique of ankle
arthrodesis, Aust N Z J Surg 62:965, 1992.
Sowa DT, Krackow KA: Ankle fusion: a new technique of internal fi xation using a compression blade plate, Foot Ankle 9:232,
1989.
Stauffer RN: Salvage of painful total ankle arthroplasty, Clin
Orthop Relat Res 170:184, 1982.
Stephenson KA, Kile TA, Graves SC: Estimating the insertion
site during retrograde intramedullary tibiotalocalcaneal
arthrodesis, Foot Ankle 17:781, 1996.
Stewart MJ, Beeler TC, McConnell JC: Compression arthrodesis
of the ankle: evaluation of a cosmetic modification, J Bone Joint
Surg 65A:219, 1983.
Stewart MJ, Harley SJ: Personal communication, 1978.
Stone KH, Helal B: A method of ankle stabilization, Clin Orthop
Relat Res 268:102, 1991.
Stranks GJ, Cecil T, Jeffrey IT: Anterior ankle arthrodesis with
cross-screw fi xation: a dowel graft method used in 20 cases, J
Bone Joint Surg 76B:943, 1994.
Stuart MJ, Morrey BF: Arthrodesis of the diabetic neuropathic
ankle joint, Clin Orthop Relat Res 253:209, 1990.
Swrd L, Hughes JS, Howell CJ, et al: Posterior internal compression arthrodesis of the ankle, J Bone Joint Surg 74B:752,
1992.
Thordarson DB, Markolf K, Cracchiolo A III: Stability of an
ankle arthrodesis fi xed by cancellous bone screws compared to
that fi xed by an external fi xator: a biomechanical study, J Bone
Joint Surg 74A:1050, 1992.

Ch003-A03329.indd 205

205

Thordarson DB, Markolf KL, Cracchiolo A III: External fi xation


in arthrodesis of the ankle: a biomechanical study comparing
a unilateral frame with a modified transfi xion frame, J Bone
Joint Surg 76A:1541, 1994.
Turan I, Wredmark T, Fellander-Tsai L: Arthroscopic ankle
arthrodesis in rheumatoid arthritis, Clin Orthop Relat Res
320:110, 1995.
Wang GJ, Shen WJ, McLaughlin RE, et al: Transfibular compression arthrodesis of the ankle joint, Clin Orthop Relat Res
289:223, 1993.
Weltmer JB Jr, Choi SH, Shenoy A, et al: Wolf blade plate ankle
arthrodesis, Clin Orthop Relat Res 268:107, 1991.
Whitman A: Astragalectomy and backward displacement of the
foot: an investigation of its practical results, J Bone Joint Surg
4:266, 1922.
Williams JE Jr, Marcinko DE, Lazerson A, et al: The Calandruccio
triangular compression device: a schematic introduction, J Am
Podiatr Assoc 10:536, 1983.
Knee
Bigliani LU, Rosenwasser MP, Caulo N, et al: The use of pulsing
electromagnetic fields to achieve arthrodesis of the knee following failed total knee arthroplasty: a preliminary report, J
Bone Joint Surg 65A:480, 1983.
Bosworth DM: Knee fusion by the use of a three-fl anged nail, J
Bone Joint Surg 28:550, 1946.
Brashear H, Hill R: The value of intramedullary nail for knee
fusion particularly for the Charcot joint, Am J Surg 87:63,
1954.
Brodersen M, Fitzgerald RH Jr, Peterson LF, et al: Arthrodesis
in rheumatoid arthritis, Reconstr Surg Traumatol 61A:181,
1979.
Cameron HU: Role of total knee replacement in failed knee
fusions, Can J Surg 30:25 1987.
Cameron HU, Hu C: Results of total knee arthroplasty following
takedown of formal knee fusion, J Arthroplasty 11:732, 1996.
Chapchal G: Intramedullary pinning for arthrodesis of the knee
joint, J Bone Joint Surg 30A:728, 1948.
Charnley J: Positive pressure in arthrodesis of the knee joint, J
Bone Joint Surg 30B:478, 1948.
Charnley J, Baker SL: Compression arthrodesis of the knee: a
clinical and histological study, J Bone Joint Surg 34B:187,
1952.
Charnley J, Lowe HB: A study of the end-results of compression
arthrodesis of the knee, J Bone Joint Surg 40B:633, 1958.
Cheng SL, Gross AE: Knee arthrodesis using a short locked
intramedullary nail: a new technique, Am J Knee Surg 8:56,
1995.
Damon TA, McBeath AA: Arthrodesis following failed total
knee arthroplasty: comprehensive review and meta-analysis of
recent literature, Orthopedics 18:361, 1995.
Donley BG, Matthews LS, Kaufer H: Arthrodesis of the knee
with an intramedullary nail, J Bone Joint Surg 73A:907, 1991.
Ellingsen DE, Rand JA: Intramedullary arthrodesis of the knee
after failed total knee arthroplasty, J Bone Joint Surg 76A:870,
1994.
Fern ED, Stewart HD, Newton G: Curved Kntscher nail
arthrodesis after failure of knee replacement, J Bone Joint Surg
71B:588, 1989.
Figgie HE III, Brody GA, Inglis AE, et al: Knee arthrodesis following total knee arthroplasty in rheumatoid arthritis, Clin
Orthop Relat Res 224: 237, 1987.
Goldberg JA, Drummond RP, Bruce WJM, et al: Huckstep nail
arthrodesis of the knee: a salvage for infected total knee
replacement, Aust N Z J Surg 59:147, 1989.

5/31/2007 12:10:24 PM

206

Part II Arthrodesis

Hak DJ, Lieberman JR, Finerman GA: Single plane and biplane
external fi xators for knee arthrodesis, Clin Orthop Relat Res
316:134, 1995.
Hankin F, Louie KW, Matthews LS: The effect of total knee
arthroplasty prostheses design on the potential for salvage
arthrodesis: measurements of volumes, lengths, and trabecular
bone contact areas, Clin Orthop Relat Res 155:52, 1981.
Harris IE, Leff AR, Gitelis S, et al: Function after amputation,
arthrodesis, or arthroplasty for tumors about the knee, J Bone
Joint Surg 72A:1477, 1990.
Hessmann M, Gotzen L, Baumgaertel F: Knee arthrodesis
with a unilateral external fi xator, Acta Chir Belg 96:123,
1996.
Hibbs RA, von Lackum HL: End-results in treatment of knee
joint tuberculosis, JAMA 85:1289, 1925.
Holden DL, Jackson DW: Considerations in total knee arthroplasty following previous knee fusion, Clin Orthop Relat Res
227:223, 1988.
Jorgensen PS, Torholm C: Arthrodesis after infected knee arthroplasty using long arthrodesis nail: a report of five cases, Am J
Knee Surg 8:110, 1995.
Key J: Positive pressure in arthrodesis for tuberculosis of the knee
joint, South Med J 25:909, 1932.
Kim YH, Kim JS, Cho SH: Total knee arthroplasty after spontaneous osseous ankylosis and takedown of formal knee fusion,
J Arthroplasty 15:453, 2000.
Knutson K, Lidgren L: Arthrodesis after infected knee arthroplasty using an intramedullary nail: reports of four cases, Arch
Orthop Trauma Surg 100:49, 1982.
Knutson K, Lindstrand A, Lidgren L: Arthrodesis for failed knee
arthroplasty: a report of 20 cases, J Bone Joint Surg 67B:47,
1985.
LaVelle DG: Knee fusion nail: technique manual, Memphis, Tenn,
1997, Smith & Nephew.
Lucas DB, Murray WR: Arthrodesis of the knee by doubleplating, J Bone Joint Surg 43A:795, 1961.
Moore FH, Smillie JS: Arthrodesis of the knee joint, Clin Orthop
13:215, 1959.
Morrey BF, Shives TC: The knee: arthrodesis. In Morrey BF,
ed: Reconstructive surgery of the joints, 2nd ed, New York, 1996,
Churchill Livingstone.
Morrey BF, Westholm F, Schoifet S, et al: Long-term results of
various treatment options for infected total knee arthroplasty,
Clin Orthop Relat Res 248:120, 1989.
Nichols SJ, Landon GC, Tullos HS: Arthrodesis with dual plates
after failed total knee arthroplasty, J Bone Joint Surg 73A:1020,
1991.
Osgood RB: The end results of excision of the knee for tuberculosis with and without the use of bone plates, Boston Med
Surg J 169:123, 1913.
Papilion JD, Heidt RS Jr, Miller EH, et al: Arthroscopic-assisted
arthrodesis of the knee, Arthroscopy 7:237, 1991.
Phillips HT, Mears DC: Knee fusion with external skeletal fi xation after an infected hinge prosthesis: a case report, Clin
Orthop Relat Res 151:147, 1980.
Pritchett JW, Mallin BA, Matthews AC: Knee arthrodesis with
a tension-band plate, J Bone Joint Surg 70A:285, 1988.
Puranen J, Kortelainen P, Jalvaara P: Arthrodesis of the knee with
intramedullary nail fi xation, J Bone Joint Surg 72A:433, 1990.
Rand JA, Bryan RS, Chao EYS: Failed total knee arthroplasty
treated by arthrodesis of the knee using the Ace-Fischer apparatus, J Bone Joint Surg 69A:39, 1987.
Rasmussen MR, Bishop AT, Wood MB: Arthrodesis of the knee
with a vascularized fibular rotatory graft, J Bone Joint Surg
77A:751, 1995.

Ch003-A03329.indd 206

Stewart MJ, Bland WG: Compression in arthrodesis: a comparative study of methods of fusion of the knee in ninety-three
cases, J Bone Joint Surg 40A:585, 1958.
Stiehl JB, Hanel DP: Knee arthrodesis using combined intramedullary rod and plate fi xation, Clin Orthop Relat Res 294:238,
1993.
Stulberg SD: Arthrodesis in failed total knee replacements, Orthop
Clin North Am 13:213, 1982.
Thornhill TS, Dalziel RW, Sledge CB: Alternatives to arthrodesis for the failed total knee arthroplasty, Clin Orthop Relat
Res 170:131, 1982.
Vander Griend R: Arthrodesis of the knee with intramedullary
fi xation, Clin Orthop Relat Res 181:146, 1983.
Velazco A, Fleming LL: Compression arthrodesis of the knee and
ankle with the Hoffman external fi xator, South Med J 76:1393,
1983.
Vlasak R, Gearen PF, Petty W: Knee arthrodesis in the treatment
of failed total knee replacement, Clin Orthop Relat Res 321:138,
1995.
Waldman BJ, Mont MA, Payman KR, et al: Infected total knee
arthroplasty treated with arthrodesis using a modular nail, Clin
Orthop Relat Res 367:230, 1999.
Weiner SD, Scarborough M, Vander Griend RA: Resection
arthrodesis of the knee with an intercalary allograft, J Bone
Joint Surg 78A:185, 1996.
Wilde AH, Stearns KL: Intramedullary fi xation for arthrodesis
of the knee after infected total knee arthroplasty, Clin Orthop
Relat Res 248:87, 1989.
Windsor RE: Arthrodesis. In Insall JN, ed: Surgery of the knee,
2nd ed, New York, 1995, Churchill Livingstone.
Wolf RE, Scarborough MT, Enneking WF: Long-term followup of patients with autogenous resection arthrodesis of the
knee, Clin Orthop Relat Res 358:36, 1999.
Woods GW, Lionberger DR, Tullos HS: Failed total knee arthroplasty: revision and arthrodesis for infection and noninfectious
complications, Clin Orthop Relat Res 173:184, 1983.
Hip
Abbott LC, Fischer FJ: Arthrodesis of the hip, with special reference to the method of securing ankylosis in massive destruction of joint, Surg Gynecol Obstet 52:863, 1931.
Abbott LC, Lucas DB: Arthrodesis of the hip in wide abduction,
J Bone Joint Surg 36A:1129, 1954.
Abbott LC, Lucas DB: Arthrodesis of the hip: a two-stage
method for difficult cases, Surg Clin North Am 36:1035, 1956.
Albee FH: Arthritis deformans of the hip: a preliminary report
of a new operation, JAMA 50:1977, 1908.
Albee FH: Extraarticular arthrodesis of the hip for tuberculosis,
Ann Surg 89:404, 1929.
Barnhardt T, Stiehl JB: Hip fusion in young adults, Orthopedics
19:303, 1996.
Benaroch TE, Richards BS, Haideri N, et al: Intermediate
follow-up of a simple method of hip arthrodesis in adolescent
patients, J Pediatr Orthop 16:30, 1996.
Blasier RB, Holmes JR: Intraoperative positioning for arthrodesis
of the hip with the double beanbag technique, J Bone Joint Surg
72A:766, 1990.
Bosworth DM: Femoro-ischial transplantation, J Bone Joint Surg
24:38, 1942.
Brien WW, Golz RJ, Kuschner SH, et al: Hip joint arthrodesis
utilizing anterior compression plate fi xation, J Arthroplasty
9:171, 1994.
Brittain HA: Ischiofemoral arthrodesis, Br J Surg 29:93, 1941.
Brittain HA: Ischio-femoral arthrodesis, J Bone Joint Surg 30B:642,
1948.

5/31/2007 12:10:24 PM

Chapter 3 Arthrodesis of the Ankle, Knee, and Hip

Callaghan JJ, Brand RA, Pedersen DR: Hip arthrodesis: a longterm follow-up, J Bone Joint Surg 67A:1328, 1985.
Carnesale PG: Arthrodesis of the hip: a long-term study, Orthop
Digest 4:12, 1976.
Chandler FA: Hip-fusion operation, J Bone Joint Surg 15:947,
1933.
Charnley J: Stabilisation of the hip by central dislocation. In
Proceedings of the British Orthopaedic Association, May 1955,
J Bone Joint Surg 37B:514, 1955 (abstract).
Davis JB: The muscle-pedicle bone graft in hip fusion, J Bone
Joint Surg 36A:790, 1954.
Davis JB, Fagan TE, Beals RK: Follow-up notes on articles
previously published in the journal: muscle-pedicle bone graft
in hip fusion, J Bone Joint Surg 53A:1645, 1971.
Duncan CP, Spahgehl M, Beauchamp C, et al: Hip arthrodesis:
an important option for advanced disease in the young adult,
Can J Surg 38(suppl 1):39, 1995.
Freiberg JA: Experiences with the Brittain ischio-femoral arthrodesis, J Bone Joint Surg 28:501, 1946.
Ghormley RK: Use of the anterior superior spine and crest of
ilium in surgery of the hip joint, J Bone Joint Surg 13:784,
1931.
Gill AB: Arthrodesis for ununited fracture of the neck of the
femur, J Bone Joint Surg 21:710, 1939.
Girdlestone GR: Arthrodesis and other operations for tuberculosis of the hip. In Robert Jones Birthday Volume, London, 1928,
Oxford University Press.
Greiss MD, Thomas RJ, Freeman MA: Sequelae of arthrodesis
of the hip, J Roy Soc Med 73:497, 1980.
Heusner: Resektion in einem Fall von angeborener Hftluxation,
Zentralbl Chir vol 45, 1884.
Hibbs RA: A preliminary report of twenty cases of hip
joint tuberculosis treated by an operation devised to
eliminate motion by fusing the joint, J Bone Joint Surg 8:522,
1926.
King D: Arthrodesis of the adult nontuberculous hip, Stanford
Med Bull 13:381, 1955.
Kirkaldy-Willis WH: Ischio-femoral arthrodesis of the hip in
tuberculosis: an anterior approach, J Bone Joint Surg 32B:187,
1950.
Kirkaldy-Willis WH, Chaudhri MR, Anderson RJD: Arthrodesis
of the hip with staple fi xation, J Bone Joint Surg 40A:114,
1958.
Klemme WR, James P, Skinner SR: Results of hip arthrodesis
in adolescents by using the cobra-head plate for internal fi xation, J Pediatr Orthop 18:648, 1998.
Kocher T: Textbook of operative surgery, London, 1911, A&C
Black.
Kostuik J, Alexander D: Arthrodesis for failed hip arthroplasty,
Clin Orthop Relat Res 188:173, 1984.
Kreder HJ, Williams JI, Jaglal S, et al: A population study in the
province of Ontario of the complications after conversion of
hip or knee arthrodesis to total joint replacement, Can J Surg
42:433, 1999.
Kntscher G: Practice of intramedullary nailing, Springfield, Ill,
1967, Charles C Thomas.
Maragliano D: Nuovi punti di appoggio chirurgico nelle lussazione vere da coxite, Chir Organi Mov 5:225, 1921.
Mayer L: Critique of Brittain operation for fusion of the hip, Bull
Hosp Jt Dis 9:4, 1948.
McKee GK: Arthrodesis of the hip with a lagscrew, J Bone Joint
Surg 39B:477, 1957.
Moore AT: Orthopaedic Correspondence Club Letter, May 1948.

Ch003-A03329.indd 207

207

Morris JB: Charnley compression arthrodesis of the hip, J Bone


Joint Surg 48B:260, 1966.
Mowery CA, Houkom JA, Roach JW, et al: A simple method of
hip arthrodesis, J Pediatr Orthop 6:7, 1986.
Murrell GA, Fitch RD: Hip fusion in young adults, using a
medial displacement osteotomy and cobra plate, Clin Orthop
Relat Res 300:147, 1994.
Pagnano MW, Cabanela ME: The hip: arthrodesis. In Morrey
BF, ed: Reconstructive surgery of the joints, 2nd ed, New York,
1996, Churchill Livingstone.
Perugia L, Santori FS, Mancini A, et al: Conversion of the
arthrodesed hip to a total hip arthroplasty: indications and
limitations, Ital J Orthop Traumatol 18:145, 1992.
Price CT, Lovell WW: Thompson arthrodesis of the hip in children, J Bone Joint Surg 62A:1118, 1980.
Reikers O, Bjerkreim I, Gundersson R: Total hip arthroplasty
for arthrodesed hips: 5- to 13-year results, J Arthroplasty 10:529,
1995.
Rittmeister M, Starker M, Zichner L: Hip and knee replacement
after long-standing hip arthrodesis, Clin Orthop Relat Res
371:136, 2000.
Roberts CS, Fetto JF: Functional outcome of hip fusion in the
young patient: follow-up study of 10 patients, J Arthroplasty
5:89, 1990.
Rocher HL: Simplified technique for extraarticular arthrodesis
of the hip by means of tibial graft (Technique simplifie pour
larthrodese extraarticulaire de la hanche par greffon tibial dans
la coxalgie type 37), J Bone Joint Surg 19:1160, 1937 (abstracted
from J de med de Bordeaux 114:69, 1937).
Schneider R: Hip arthrodesis with the cobra head plate and
pelvic osteotomy, Reconstr Surg Traumatol 14:1, 1974.
Sofue M, Kono S, Kawaji W, et al: Long-term results of arthrodesis for severe osteoarthritis of the hip in young adults, Int
Orthop 13:129, 1989.
Sponseller PD, McBeath AA, Perpich M: Hip arthrodesis in
young patients: a long-term follow-up study, J Bone Joint Surg
66A:853, 1984.
Sponseller PD, McBeath AA, Perpich M: Long-term follow-up
of hip arthrodesis performed in young adults. In The hip: proceedings of the Twelfth Open Scientifi c Meeting of the Hip Society,
St Louis, 1984, Mosby.
Stewart MJ, Coker TP Jr: Arthrodesis of the hip: a review of 109
patients, Clin Orthop Relat Res 62:136, 1969.
Stone MM: Arthrodesis of the hip, J Bone Joint Surg 38A:1346,
1956.
Stratford B: The Trumble graft: a review of thirty-six cases, J
Bone Joint Surg 35B:247, 1953.
Trumble HC: A method of fi xation of the hip-joint by means of
an extraarticular bone graft, Aust N Z J Surg 1:413, 1932.
Trumble HC: Fixation of the hip joint by means of an extraarticular bone graft: late results, Br J Surg 24:728, 1937.
Waters RL, Barnes G, Husserl T, et al: Comparable energy
expenditure after arthrodesis of the hip and ankle, J Bone Joint
Surg 70A:1032, 1988.
Watson-Jones R: Arthrodesis of the osteoarthritic hip, JAMA
110:278, 1938.
Watson-Jones R, Robinson WC: Arthrodesis of the osteoarthritic
hip joint, J Bone Joint Surg 38B:353, 1956.
White JW: Smith-Petersen nail fi xation in hip surgery, AAOS
Instr Course Lect 1:143, 1934.
White RE Jr: Arthrodesis of the hip. In The hip: proceedings of the
Twelfth Open Scientifi c Meeting of the Hip Society, St Louis, 1984,
Mosby.

5/31/2007 12:10:25 PM

Arthrodesis of the
Shoulder, Elbow,
and Wrist
Chapter 4

Shoulder arthrodesis ...............


History ........................................
Indications ..................................
Position .......................................
Surgical techniques .....................
Complications .............................

Gregory Dabov

208
208
209
211
212
218

Elbow arthrodesis ...................


Indications ..................................
Surgical techniques .....................
Complications .............................

219
219
219
223

Wrist arthrodesis ..................... 224

This chapter discusses the indications and techniques for


arthrodesis of the shoulder, elbow, and wrist joints. The
general principles of arthrodesis outlined in Chapter 3 also
are applicable here. Arthrodesis is performed even more
rarely in the upper extremity than in the lower extremity
because of the infrequent occurrence of disorders that are
so disabling that the patient is willing to sacrice motion
in the shoulder or elbow. The development of successful
arthroplasty of the shoulder and elbow also has shortened
the list of indications. Arthrodesis of the wrist continues
to be a relatively common procedure, however. The indications and techniques for limited arthrodesis of the wrist
and arthrodesis of the hand are discussed in Chapter 66.

SHOULDER ARTHRODESIS
History
Around the turn of the 20th century, shoulder arthrodesis
was a relatively common procedure. Indications at that
time were mainly for upper extremity paralysis caused by
polio or shoulder joint destruction caused by tuberculosis.
Because the procedure was so successful, the list of indications grew over the next several decades. The earliest techniques did not employ internal or external xation devices.
A purely extraarticular technique of shoulder arthrodesis
was recommended for tuberculous infection to prevent
invasion from the infected joint. With the advent of antitubercular drugs, however, this technique became unneces-

History ........................................
Indications ..................................
Position .......................................
Surgical techniques .....................
Complications .............................

224
224
224
225
228

sary. Later procedures were described that placed various


types of bone graft into the beds of the decorticated glenohumeral or acromiohumeral joints, or both. These procedures all required prolonged spica casting.
Internal xation is now recommended because external
support alone rarely maintains complete xation of the
shoulder. Internal xation allows better stabilization of
contact surfaces and promotes fusion. Also, if rigid internal
xation is used, casts, splints, and braces may be avoided
altogether, allowing early restoration of function of the
extremity.
In the early 1950s, Charnley introduced the use of
external xation to apply compression across the fusion
site. The external xator was removed at 6 weeks, and a
spica cast was worn for 3 months. Fusion rates with external xation alone generally were poor. Most studies
employing Charneys technique reported fusion rates
greater than 90%. External xation is still useful in certain
patients, especially if infection is present or trauma has
occurred with signicant soft-tissue injury.
In 1957, Carroll suggested using a wire loop to connect
the glenoid and humeral head, allowing postoperative
changing of arm position. In this technique, a 22-gauge
wire is routed through the humeral head and the anterosuperior quadrant of the glenoid, exiting the glenoid neck
inferior to the coracoid process. If indicated, Carroll suggested adjusting the cast position during the second postoperative week to maximize clinical function. In 1998,
Mohammed reported a 94% fusion rate in 18 patients using
a Rush rod and tension band with a muscle-pedicle graft.

208

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Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

These techniques can be considered when limited internal


hardware is desired, or if one is working in an environment
where there is a paucity of modern implants. Long-term
spica casting is still required.
The 1960s saw the introduction of internal xation for
shoulder arthrodesis. In separate reports, Moseley and May
described a technique using internal xation with two
screws. Charnley and Houston described a technique that
combined external xation with internal xation using
screws. Successful results also were reported using Steinmann
pins to obtain shoulder fusion. Some authors still support
the use of screws for shoulder arthrodesis. Advantages of
screw over plate xation are less soft-tissue dissection, a
lower infection rate, a decreased rate of postoperative
humeral fractures, and a lesser need to remove painful
hardware. Disadvantages of screw xation are a higher
nonunion rate and the need for prolonged spica casting.
In 1970, the AO group published its technique of plate
and screw xation to allow mobilization of the patient
without a spica cast. Kostuik and Schatzker introduced the
use of a second posterior buttress plate and obtained union
in all 18 shoulders they repaired using this technique.
Miller et al. performed a biomechanical study of various
xation techniques used for shoulder arthrodesis (Fig. 4-1);
double plating (4.5 dynamic compression plate) was found
to have the highest bending strength and torsional stiffness.
This construct was followed in decreasing strength by
single plating, external xation combined with screws,
external xation alone, and screws alone. Conversely,
Rhmann et al. compared various six-screw congurations
with a reconstruction plate. In a cadaver study, they showed
that certain screw congurations are as mechanically stable
as a 16-hole reconstruction plate, and they found no signicant difference in construct strength between the two
groups.
In the late 1980s, Richards et al. described a technique
using a malleable pelvic reconstruction plate without bone
grafting followed by 6 postoperative weeks of spica casting.
They obtained solid fusion in all 11 patients with brachial
plexus injuries. The advantages of the reconstruction plate
over the dynamic compression plate include intraoperative
contouring and less prominent hardware.

209

Shoulder arthrodesis rarely is indicated for osteoarthritis,


rheumatoid arthritis, or posttraumatic arthritis because
these are better treated with shoulder arthroplasty.
Contraindications to shoulder arthrodesis include osteonecrosis, for which shoulder joint replacement is more appropriate; Charcot arthropathy, in which the nonunion rate is
unacceptably high; ipsilateral elbow fusion; and contralateral shoulder fusion. Current indications for shoulder
arthrodesis are listed in Box 4-1. Bacterial or tubercular
infections uncontrolled with medication or dbridements
often result in pain and joint incongruency. In patients
with persistent infection, arthroplasty is contraindicated,
and arthrodesis with limited internal xation, with or
without external xation, often is successful. In these cases,
it is important to dbride the shoulder adequately of any
infected tissue or bony sequestra.
Shoulder arthrodesis is still commonly used for stabilization in paralytic disorders. Obstetrical plexus injuries may
be best treated with arthrodesis near skeletal maturity,
because growth arrests and position changes are less of a
concern. Some authors recommend combining shoulder
arthrodesis with transhumeral amputation and prosthetic
tting in patients with complete brachial plexus palsies.
Although a minimum age of 10 to 12 years has been suggested, in a review of shoulder arthrodesis in 102 children,
signicant growth arrest occurred in only 1, an 11-year-old
patient. Makin endorsed early arthrodesis for children older
than 6 years of age who had an irreversible ail shoulder
with adequate scapulothoracic muscles, acute elbow exors,
and a functional hand with skin sensibility. Shoulder
arthrodesis commonly is used in adult patients with ail
limbs caused by traumatic brachial plexus injuries.
In patients with combined deltoid and rotator cuff paralysis or insufciency, arthrodesis is preferable to arthroplasty, because they lack the muscle power to achieve
adequate function. Shoulder arthrodesis can be considered
for patients with massive irreparable cuff tears associated
with glenohumeral arthritis, especially young patients who
require strength in waist-level activities rather than
movement.
Arthrodesis also is an option for failed shoulder arthroplasty when revision is impossible. Usually revision is
limited by infection, but massive rotator cuff loss or sig-

Indications
Indications for shoulder fusion have diminished over the
years because of the excellent results of shoulder arthroplasty, the near-elimination of poliomyelitis and tuberculosis, and the improved techniques for shoulder stabilization.
Nevertheless, shoulder arthrodesis is still a useful procedure
for many conditions. Some scapulothoracic and trapezius
muscle function improves the overall joint stability and
allows movement at the scapulothoracic joint, and scapular
rotation is increased further if serratus anterior muscle
function is present.

Ch004-A03329.indd 209

Box 4-1 Indications for Glenohumeral


Arthrodesis
Infection
Paralytic disorders
Unreconstructable rotator cuff tears
Combined insufciency of rotator cuff and deltoid
Failed shoulder arthroplasty
Arthritic diseases unsuitable for arthroplasty
Recurrent dislocations
Neoplastic lesions

5/31/2007 12:12:12 PM

E
Fig. 4-1 Fixation techniques for shoulder arthrodesis (posterior view). A, Screws alone. B,
External xation alone. C, External xation with screws. D, Single-plate xation. E, Doubleplate xation. (Redrawn from Miller BS, Harper WP, Gillies RM, et al: Biomechanical analysis of
ve xation techniques used in glenohumeral arthrodesis, Aust N Z J Surg 73:1015, 2003.)

Ch004-A03329.indd 210

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Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

nicant bone loss also may preclude revision. Resection


arthroplasty may be preferable to arthrodesis because of the
technical difculties and generally poor outcomes of
arthrodesis after failed total shoulder arthroplasty.
Other indications for shoulder arthrodesis include recurrent shoulder dislocations that persist after multiple surgical
procedures, multidirectional instability, voluntary dislocations associated with glenohumeral arthritis, and tumor
resections, which may require an allograft. Rarely, arthrodesis can be considered for arthritic diseases, such as inammatory arthritis with severe rotator cuff involvement, for
which arthroplasty is inappropriate. A physical laborer with
painful arthritis who is not required to perform overhead
lifting often can function better with arthrodesis than with
shoulder arthroplasty.

Position
The proper position of the arm at the time of arthrodesis
is controversial. In 1974, Rowe recognized the advantages
of minimizing abduction and exion (Fig. 4-2). In a study
of 71 shoulder arthrodeses, Coeld and Briggs found the
amount of internal rotation to be the most important factor
in determining the functional success of the operation.
Hawkins and Neer performed a functional analysis in 17
patients who had shoulder arthrodesis and identied a
range of acceptable positions. They recommended 25 to 40
degrees of abduction, 20 to 30 degrees of exion, and 25

to 30 degrees of internal rotation. In a 1997 study on the


treatment of complications of shoulder fusions, Groh et al.
performed reconstructive osteotomies in 9 patients with
symptomatic malunion after shoulder arthrodesis. In their
study, malposition that necessitated operative treatment was
dened as greater than 15 degrees of exion and rotation
less than 40 degrees or more than 60 degrees. We agree
that the position of rotation is the most crucial factor in
obtaining optimal function.
Abduction can be determined at the time of surgery
by clinically measuring the angle formed by the body and
the humerus. This angle, or an angle specically determined preoperatively, can be determined by obtaining an
anteroposterior radiographic view using the spine rather
than the border of the scapula as a landmark, as recommended by Ingram and Miller. Flexion is determined by
observing the angle that the humerus forms with the horizontal plane in a supine patient. After the positions of
abduction and exion have been determined, the elbow is
exed to 90 degrees. The hand is positioned over the ipsilateral area of the chest between the sternum and axilla so
that further exion of the elbow allows the top of the
thumb to touch the chin (Fig. 4-3). Davis and Cottrell
recommended pinning the glenohumeral joint before
surgery to determine optimal position. Some authors have
recommended shoulder arthrodesis through a split spica
cast that was positioned and applied before surgery using
any of the techniques described subsequently. This makes

40

20

30

Abduction 20

211

Internal rotation
40

40
Internal rotation
40

Forward flexion
30

Fig. 4-2 Position of arm for arthrodesis of shoulder as recommended by Rowe: 20 degrees of
abduction (clinical measurement), 30 degrees of forward exion, and 40 to 50 degrees of internal
rotation. (Redrawn from Rowe CR: Re-evaluation of the position of the arm in arthrodesis of the
shoulder in the adult, J Bone Joint Surg 56A:913, 1974.)

Ch004-A03329.indd 211

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212

Part II Arthrodesis

patient with signicant soft-tissue loss or deciency. This


technique also is useful in infections that are difcult to
treat.

TECHNIQUE 4-1

Charnley and Houston

First apply the trunk portion of a shoulder spica cast with the
patient awake; allow it to harden and then bivalve it and save it
for use later.

B
Fig. 4-3 Method of determining appropriate internal rotation for arthrodesis of shoulder. A, Hand positioned midway
between sternum and axilla. B, Further exion of elbow
should allow tip of thumb to strike chin. (Redrawn from
Hawkins RJ, Neer CS II: A functional analysis of shoulder
fusions, Clin Orthop 223:65, 1987.)

surgery quite cumbersome, however, and we do not recommend this practice.

Surgical Techniques
When choosing the technique to be used, an attempt at
fusion should be made between the acromion and humeral
head and the glenohumeral joint. Stable internal xation
can reduce the need for bone grafting and external xation
or spica casting. Postoperative use of a premade custom
orthosis is generally well tolerated by most patients and
can be considered for any of the techniques described
subsequently.
Shoulder arthrodesis without implants or compression is
primarily of historical interest. The techniques of WatsonJones, Putti, Steindler, Brett, and Gill are not included in
this edition because they are rarely indicated. For details
of these techniques, the reader may refer to earlier editions
of this textbook or the original articles cited in the reference section of this chapter.

Position the patient in a semireclining or beach-chair posture


and make a saber-cut incision centered over the lateral border
of the acromion.
Using electrocautery, take down the anterior and lateral
deltoid muscle, and tag and retract this muscle.
Excise the soft tissue from the subacromial space. Denude
the upper half of the glenoid fossa of articular cartilage and
the undersurface of the acromion to bleeding bone. Remove
the articular cartilage from the humeral head and reduce the
joint.
With an osteotome, split off the greater tuberosity, and resect
enough bone from the humeral head to allow it to sublux
superiorly against the undersurface of the acromion and the
superior part of the glenoid fossa (Fig. 4-4). Use the resected
bone as graft material around the fusion. Insert a 4-mm pin from
the posterosuperior aspect of the acromion into the scapular
neck deep to the glenoid fossa (Fig. 4-5). Another pin can be
placed in the base of the coracoid process.
Insert a second set of similar pins into the surgical neck of the
humerus posterolaterally perpendicular to the shaft of the
humerus.
Construct an external frame of adjustable pin clamps and bars,
and connect it to the pins for application of compression with
the arm in the desired position for arthrodesis.
Reattach the deltoid to the acromion, and close the wound in
layers over a drain.
Apply the previously made part of the shoulder spica cast, and
complete it, incorporating the external xator.

External Fixation
Charnley described a procedure to accomplish shoulder
arthrodesis by applying external compression. In 1964,
Charnley and Houston modied this technique to allow
easier adjustment of arm position. They reported radiographic evidence of fusion in 22 of 23 patients at an average
follow-up of 6.5 years; 1 patient had a clinically stable,
asymptomatic shoulder without radiographic evidence of
fusion. Schroder and Frandsen reported successful arthrodesis in 15 of 16 patients using the technique of Charnley
and Houston; in the remaining patient, the shoulder healed
after a second procedure with autogenous bone grafts.
External xation, preferably with screw supplementation,
should be considered when an arthrodesis is indicated in a

Ch004-A03329.indd 212

Fig. 4-4 Charnley and Houston technique of compression


arthrodesis of shoulder. Graft is raised, and denuded humeral
head is apposed to glenoid and undersurface of acromion.
(Redrawn from Charnley J, Houston JK: Compression arthrodesis of the shoulder, J Bone Joint Surg 46B:614, 1964.)

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Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

213

Deltoid origin
incision
Shoulder strap
incision

Fig. 4-5 Arrangement of pins and compression clamps in


compression arthrodesis of shoulder. Pins penetrate from
lateral aspect and do not transx shoulder, requiring only
two skin perforations. (From Charnley J, Houston JK:
Compression arthrodesis of the shoulder, J Bone Joint Surg 46B:614,
1964.)

Fig. 4-6 Incision of deltoid origin from clavicle and anterior


and lateral acromion. Incision may continue along spine of
scapula if plate is to be placed for internal xation. (Redrawn
from Coeld RH: Arthrodesis and resectional arthroplasty of the
shoulder. In Evarts CM, ed: Surgery of the musculoskeletal system,
ed 2, New York, 1990, Churchill Livingstone.)

AFTERTREATMENT The pins and external xator are


removed at 5 to 6 weeks, and the cast is changed. The
second cast is removed at 12 weeks from the time of
surgery, and the shoulder is examined for stability.
Immobilization is continued until the arthrodesis is solid.

Screw Fixation
Coeld described a shoulder fusion technique using screw
xation through a strap incision that may be extended
posteriorly if needed (Fig. 4-6). The position and number
of screws (Fig. 4-7) used vary depending on the indication
for arthrodesis and the condition of the bone at the time
of surgery. Rhmann et al. described a fusion technique
using six screws (Fig. 4-8). Mechanical studies have shown
this conguration to be as strong as a reconstruction plate.
Long-term clinical data presently are lacking. Advantages
of screw over plate xation include less soft-tissue dissection, lower infection rate, a decreased rate of postoperative
humeral fractures, and a lesser need to remove painful
hardware. Current data still show a higher nonunion rate
with screw xation, however, compared with plate xation. A good option, in the face of severe infection or tissue

Ch004-A03329.indd 213

Fig. 4-7 Humeral head secured to scapula with screws.


(Redrawn from Coeld RH, Briggs BT: Glenohumeral arthrodesis: operative and long-term functional results, J Bone Joint Surg
61A:668, 1979. By permission of Mayo Foundation for Medical
Education and Research.)

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214

Part II Arthrodesis

Assess the arm position. If it is acceptable, replace the


Steinmann pins with cancellous screws over washers (see Figs. 47 and 4-8). Place one to three screws through the acromion and
into the humeral head.

Place a drain deep to the deltoid, and attach the deltoid


proximally to the trapezius while covering the plate.

AFTERTREATMENT

A pelvic band extending from the


nipples to the pubic symphysis is applied. With the elbow
exed 90 degrees, a cylinder cast is applied to the upper
extremity. The extremity is suspended by two wooden
struts, or a cock-up wrist splint is used. At 1 to 2 weeks
after surgery, a plastic shoulder spica cast is applied and
worn until union is achieved, 12 to 16 weeks after
surgery.
Fig. 4-8 Shoulder arthrodesis with three humeroglenoid
screws and three acromiohumeral screws. (Redrawn from
Rhmann O, Kirsch L, Buch S, et al: Primary stability of shoulder arthrodesis using cannulated cancellous screws, J Shoulder
Elbow Surg 14:51, 2005.)

loss, is limited internal xation with screws combined with


an external xator.

TECHNIQUE 4-2 Coeld


Place the patient in the beach-chair position.
Make an anterosuperior shoulder strap incision.
Remove the deltoid from the anterior and lateral acromion and
from the lateral clavicle.
Incise the rotator cuff longitudinally in the supraspinatus and
transversely from anterior to posterior. Remove the proximal
biceps tendon from the superior glenoid.

If the acromioclavicular joint is arthritic, perform a distal


clavicle excision.
Position the upper extremity in 45 degrees of abduction,
exion, and internal rotation. Flexion and abduction may need to
be adjusted to 30 degrees to allow the thumb, with the forearm
in neutral, to touch the nose.

Dbride the bony surfaces, especially the humeral head, to


increase surface contact areas.
Denitive xation is determined by the indication for
arthrodesis and by the status of bone stock. Drill two or three
1
/8-inch Steinmann pins or guidewires for cannulated screws
through the humeral head and into the glenoid to secure the
humerus to the scapula.

Ch004-A03329.indd 214

Posterior Approach
Uematsu successfully used a posterior shoulder approach for
an intraarticular and extraarticular arthrodesis combined
with internal xation in six consecutive arthrodeses.

TECHNIQUE 4-3

Uematsu

Position the patient on the unaffected side and make an


incision 10 to 12 cm long extending laterally from the middle of
the scapular spine along the spine and ending 2.5 cm distal to
the acromion (Fig. 4-9A).
Detach the deltoid and trapezius from the scapular spine (Fig.
4-9B), and expose the supraspinatus and infraspinatus and
retract them out of the way.
Make an oblique osteotomy from the lateral third of the
scapular spine to the spinoglenoid notch and lateral third of the
acromion without entering the acromioclavicular joint (Fig. 4-9C).
The osteotomized fragment may be used as a muscle-pedicle
bone graft if the deltoid attachment is retained. Otherwise, it
may be used as a free graft.
Divide the tendinous attachments of the supraspinatus and
infraspinatus about 1.5 cm from their insertions on the greater
tuberosity.

Remove all articular cartilage from the glenoid fossa and


humeral head (Fig. 4-9D) and decorticate the posterior aspect of
the glenoid fossa.
Position the arm in 20 degrees of abduction, 30 degrees of
forward exion, and 40 degrees of internal rotation. This is
determined clinically with the arm at the side of the body.
Insert three ASIF cancellous screws through the humeral head
into the glenoid fossa and scapular neck (Fig. 4-9E). Check for
stability and use additional screws if necessary.

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Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

215

A
Deltoid muscle

Trapezius
muscle

Periosteum

Fig. 4-9 AE, Technique of shoulder arthrodesis through posterior approach (see text).
(Redrawn from Uematsu A: Arthrodesis of the shoulder: posterior approach, Clin Orthop 139:169,
1979.)

Fix the acromial bone graft posteriorly.


Close the wound in layers over a drain, taking care to secure a
tight closure of the trapeziodeltoid interval.

Apply a sterile dressing, and suspend the arm by overhead skin


traction.

Ch004-A03329.indd 215

AFTERTREATMENT

The dressing is changed, and the


drain is removed on the second day. With the patient
standing, a shoulder spica cast is applied. A cast is worn for
3 months or until union is solid radiographically. Then
rehabilitation of the upper extremity is begun.

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Part II Arthrodesis

Tension Band Fixation


In 1998, Mohammed reported his results of shoulder
arthrodesis using a Rush rod, tension band, and a musclepedicle graft through a posterior approach. Of 18 shoulders,
17 fused within 8 to 10 weeks. The single nonunion was
attributed to patient noncompliance.

Partially divide the distal acromion with an osteotome, and


reect it distally, leaving the deltoid attached as a vascularized
graft.
Divide the tendinous attachments of the supraspinatus and
infraspinatus about 1.5 cm from their insertions on the humerus
to expose the glenohumeral joint.

Remove the articular cartilage from the glenoid and humeral


head.
TECHNIQUE 4-4 Mohammed

Decorticate the undersurface of the acromion and lateral


aspect of the proximal humerus.

Position the patient on the unaffected side, and make an


incision along the spine of the scapula, extending distal to the
acromion (Fig. 4-10A).

Remove a small wedge of bone from the humeral head to


accommodate the acromion and its muscle-pedicle graft at the
desired position of arthrodesis.

Expose the scapular spine subperiosteally, avoiding the

With the shoulder in the desired position, drill a hole (3.2 mm)
from the dorsal surface of the scapular spine through the

acromioclavicular joint.

Fig. 4-10 Mohammed technique. A, Skin incision. B, Differing point of entry in spine of
scapula according to degree of abduction. C and D, Completed procedure with Rush pin,
tension band wiring, and muscle-pedicle bone graft (arrow). (Redrawn from Mohammed NSE-S:
A simple method of shoulder arthrodesis, J Bone Joint Surg 80B:620, 1998.)

Ch004-A03329.indd 216

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Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

217

humeral head into the medullary canal of the humerus (Fig.


4-10B).

Place a Rush rod (5 to 7 mm) through the hole, and apply a


tension band cerclage wire between the body of the acromion
and the neck of the humerus (Fig. 4-10C). The tension band is
used to press the graft into position (Fig. 4-10D).

Close the wound in layers over a drain.


ca. 70

AFTERTREATMENT

A shoulder spica cast is applied, and


movement of the wrist and elbow is allowed after 4 to 6
weeks. External support of the shoulder is maintained until
radiographic union is shown, usually at 8 to 10 weeks.

Plate Fixation
The AO group has described a double plating technique
for rigid stabilization in glenohumeral arthrodesis. Stark,
Bennett, and Tullos reported 14 of 15 patients successfully
treated with this technique and noted that its main advantage is early resumption of physical therapy because no
external xation or cast is required. Other studies support
this technique. The disadvantage is the possible need for a
second procedure to remove the implants after the arthrodesis is solid.

Fig. 4-11 Mller et al. technique of shoulder arthrodesis (see


text). (Redrawn from Mller ME, Allgower M, Willenegger H:
Manual of internal xation: techniques recommended by the AO group,
ed 2, Berlin, 1979, Springer-Verlag.)

Displace the humerus superiorly and medially to lie against the


acromion and glenoid fossa in the desired position for
arthrodesis.
Fix the plate distally with two screws that pass through it and
the humeral head and into the glenoid fossa and scapular neck.
Insert at least two more screws to x the plate to the humerus.
If the plate does not achieve complete stability at the arthrodesis
site, apply a second plate posteriorly from the scapular spine to
the humerus (Fig. 4-11).
Apply bone grafts as desired. Close the wound in layers over
drains.

TECHNIQUE 4-5

AO Group

Place the patient in the lateral decubitus position.


Make an incision along the spine of the scapula, over the
acromion, and along the proximal third of the humerus. Expose
the scapular spine, glenoid fossa, and proximal third of the
humerus.
Denude the glenoid fossa and humeral head of all cartilage.
Decorticate the undersurface of the acromion and the lateral
portion of the humerus for contact with the acromion.
An osteotomy of the acromion may be necessary to increase
surface contact between the plate and bones.

Position the humeral head in the desired position in the


glenoid fossa.
Use a malleable template to determine the contour for a
standard broad AO plate and contour the plate with bending
press and irons. The plate is to lie along the scapular spine, over
the acromion, and against the proximal third of the humerus
(Fig. 4-11).
Fasten the plate initially with a long cortical screw inserted
vertically into the scapular neck. Insert the remaining proximal
screws into the scapula using standard AO technique.

Ch004-A03329.indd 217

AFTERTREATMENT

A Velpeau dressing is applied. The


sutures are removed at 2 weeks if nonabsorbable. Active
rehabilitation of the elbow, wrist, and hand is begun within
the rst few days after surgery, but care should be taken
not to place stress on the fusion site. A double-plating
technique also can be used.

Pelvic Reconstruction Plate


Richards et al. believe the technical difculties of contouring the AO plate and the occasional problems caused by
prominent screws can be overcome by the use of a malleable pelvic reconstruction plate. They reported successful
fusion in 11 patients without the need for plate removal.
TECHNIQUE 4-6

Richards et al.

Place the patient in a semisitting position, and drape the arm


free.

Make an incision extending from the spine of the scapula to


the anterior aspect of the acromion and distally on the anterior
aspect of the humeral shaft.

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218

Part II Arthrodesis

TECHNIQUE 4-6 Richards et al.contd


Detach the deltoid muscle from the anterior aspect of the
acromion, and split the bers of the muscle distally.

Resect the rotator cuff. Decorticate the glenoid fossa, the


undersurface of the acromion, and the head of the humerus.
Support the shoulder in 30 degrees of exion, 30 degrees of
abduction, and 30 degrees of internal rotation, and measure
abduction from the side of the body. Bring the head of the
humerus proximally to appose the decorticated undersurface of
the acromion. Abducting and exing the humerus 30 degrees
apposes the head of the humerus to the undersurface of the
acromion and the glenoid fossa.
Maintain the position by supporting the arm with folded
sterile sheets, and have an assistant maintain this position while
the plate is contoured.
Use hand-held bending irons to contour a 4.5 reconstruction
plate along the spine of the scapula, over the acromion, and
down onto the shaft of the humerus. This generally requires a
12-hole to 16-hole plate. Bend the plate gently 60 degrees over
the acromion, and twist it 20 to 25 degrees just distal to the
bend to appose the shaft of the humerus (Fig. 4-12).
Insert the three screws that pass through the plate and the
head of the humerus into the glenoid fossa to compress the site
of the arthrodesis.

Direct a cortical screw from the spine of the scapula into the
base of the coracoid process. Take care not to break the drill bit
when drilling into the cortical bone in the scapula. Place a 6.5mm cancellous screw across the acromiohumeral site of fusion,
and secure the remaining holes of the plate with 4.5-mm cortical
screws.
Do not osteotomize the acromion because it is used to
augment the xation of the scapula to the humerus.
Close the wound in layers over a drain.

AFTERTREATMENT

The arm is supported with a pillow


and swathe. A shoulder spica cast is applied 48 hours after
surgery. If there is no radiographic evidence of loosening
of the internal xation device 6 weeks after surgery, the
arm is placed in a sling. Gentle range-of-motion exercises
only are allowed until union is seen on radiograph; strenuous activity is delayed for at least 16 weeks after surgery.

Complications
Complications associated with shoulder arthrodesis are
listed in Box 4-2. Immediate postoperative complications
are uncommon and mainly involve wound problems, such
as infection, skin breakdown, and wound hematoma. The
surgeon also must be mindful of pressure sores under a
spica cast. Loss of elbow motion has been reported, but
usually is temporary.
Later postoperative complications are more prevalent. In
a 1997 study by Groh et al., 9 of 28 shoulder arthrodeses
required revision surgery for malunion. These were treated
successfully with a closing wedge humeral osteotomy and
secured with a 4.5 mm reconstruction plate. Malposition
can lead to a traction neuritis or periscapular muscle strain,
especially when the arm is positioned in too much
abduction.

Box 4-2 Complications of Glenohumeral


Arthrodesis

Fig. 4-12 Richards et al. technique of arthrodesis of shoulder. Pelvic reconstruction plate is bent at fourth hole and
twisted slightly distally to appose shaft of humerus with
shoulder in 30 degrees of abduction, 30 degrees of exion,
and 30 degrees of internal rotation. (From Richards RR,
Sherman RMP, Hudson AR, et al: Shoulder arthrodesis using a
pelvic-reconstruction plate: a report of eleven cases, J Bone Joint
Surg 70A:416, 1988.)

Ch004-A03329.indd 218

Infection
Wound hematoma
Skin slough
Pressure sores under spica cast
Pseudarthrosis/nonunion
Painful hardware
Malposition
Ipsilateral humeral fracture
Traction neuritis
Periscapular muscle strain
Acromioclavicular arthritis
Epiphyseal problems/growth arrest

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Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

Sperling and Coeld reported three total shoulder


arthroplasties performed for failed shoulder arthrodesis.
Two of their three patients reported signicant pain relief
after total shoulder arthroplasty. Functional improvements
were minimal in all three patients.
Nonunion rates in most modern series are less than 10%.
Union generally is achieved with autologous bone grafting.
In a classic study by Coeld and Briggs, 24% of patients
required reoperation for removal of painful hardware.
Secondary degenerative arthritis of the acromioclavicular
joint is common. If any signs of acromioclavicular arthritis
are present preoperatively, a concurrent distal clavicle excision should be performed.
Ipsilateral humeral fractures after shoulder fusion have
been reported in 25% of patients in some series. Most
authors recommend nonoperative treatment with a shoulder spica or orthosis in these patients.

ELBOW ARTHRODESIS
Indications
Although maintaining elbow motion is desirable, total
elbow arthroplasty has not reached the level of acceptability
attained by arthroplasty of the hip, knee, or shoulder.
Major functional disability is prevented by the ability of
adjacent joints to compensate for lack of elbow motion.
Because the elbow is a nonweight bearing joint, fascial
arthroplasty or even resection arthroplasty in the presence
of functional musculature often provides better function of
the upper extremity than does elbow arthrodesis.
Indications for elbow arthrodesis are listed in Box 4-3.
In general, elbow arthrodesis is reserved for patients with
painful arthritis who are not candidates for total elbow
arthroplasty, especially individuals who place high demands
on the upper extremities, such as manual laborers. Elbow
fusion is indicated for persistent infection, including tuberculosis, which historically was the main indication for this
procedure. Elbow arthrodesis also is an option for severely
comminuted, intraarticular fractures of the distal humerus
that cannot be repaired and may be indicated after failed
total elbow arthroplasty.
For unilateral arthrodesis of the elbow, a position of 90
degrees of exion is desirable. In 1992, ONeill et al.
reported 10 healthy patients who were tted with braces
locked at 50 degrees, 70 degrees, 90 degrees, and 110

Box 4-3 Indications for Elbow Arthrodesis


Infection
Failed total joint arthroplasty
Posttraumatic arthritis
Arthritic diseases unsuitable for arthroplasty
Severely comminuted intraarticular fractures

Ch004-A03329.indd 219

degrees to simulate elbow arthrodesis and to determine


compensatory motion in the upper extremity. Fusion at 90
degrees was optimal for personal hygiene needs, whereas
fusion at 70 degrees was best for extrapersonal activities.
They concluded that there was no single optimal position
for all activities. Other authors have advocated simulation
of arthrodesis by use of preoperative splints set at varying
degrees of exion.
Bilateral elbow arthrodesis rarely is indicated because of
resultant functional limitations. If indicated, one elbow
should be placed in 110 degrees of exion to permit the
patient to reach the mouth, and the other should be placed
in 65 degrees to aid in personal hygiene. These positions
may be varied to meet the requirements of the patients
occupation.
Arthrodesis of the elbow joint is difcult because of the
unique bony anatomy of the elbow and the long lever arm
of the upper extremity distal to the elbow. For successful
elbow arthrodesis, adequate bone stock must be present,
although resection of the radial head may be necessary to
restore pronation and supination, and internal or external
xation with bone grafting must be used.

Surgical Techniques
Arthrodesis
In an early technique of arthrodesis reported by Hallock
in 1932, the olecranon was osteotomized and wedged into
the posterior distal humerus. Steindler used a tibial graft
wedged into the olecranon tip and secured it into the posterior distal humerus with screws.
TECHNIQUE 4-7

Steindler

Make a posterolateral incision from a point 10 cm above the


elbow to a point 2.5 cm below the olecranon.
With an osteotome, dissect the triceps tendon from its
insertion on the olecranon process.
Excise the hypertrophied synovium as thoroughly as possible
without removing much other soft tissue.
Excise the articular cartilage of the semilunar notch of the
olecranon and the trochlear surface of the humerus, and sh
scale the subchondral bone.

At the same time, a second surgical team should have


obtained a graft from the upper half of the tibia approximately
1.5 cm wide 9 cm long. If a second team is unavailable, obtain
this graft before entering the elbow.
Make a bed for the graft in the posterior surface of the distal
humerus and form a cleft in the superior part of the tip of the
olecranon.

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Part II Arthrodesis

TECHNIQUE 4-8

Brittain

Place the patient supine, with the arm resting on a sandbag


on a small table and the elbow at a 90-degree angle.
Take two grafts from the anteromedial surface of the tibia,
each 7.5 to 10 cm long and 8 mm wide.
Make a longitudinal incision 12.5 cm long over the posterior
aspect of the elbow joint, beginning directly over the olecranon
and continuing proximally through the triceps in the midline.
Carry the incision down to the bone, and expose and protect the
ulnar nerve.

Fig. 4-13 Arthrodesis of elbow: Steindler technique, with


posterior cortical graft.

Drill two holes, each 3.2 mm in diameter, in the olecranon


process, 1.3 cm apart. The rst should be 6 mm and the second
1.8 cm distal to the tip. Join the two by an osteotomy. These
holes are drilled to prevent splitting the bone.
Carry the osteotome proximally through the elbow joint in line
with the shaft of the humerus but inclined slightly anteriorly for
7.5 cm.

Make a similar opening in the lateral aspect of the humerus


TECHNIQUE 4-7

Steindlercontd

With the elbow in exion, t the graft into the olecranon


cleft, and then, after extending the elbow to the position of
fusion, place it in its humeral bed.

Insert one or two screws through the graft into the humerus
to make it secure (Fig. 4-13).

Pack the ulnohumeral joint with cancellous bone from the


proximal end of the tibia.

just proximal to the olecranon fossa.

While retaining the rst osteotome in position, introduce a


second in the long axis of the shaft of the ulna at a right angle
to the humerus, but inclining slightly posteriorly. By leaving the
rst osteotome in position, the second is able to avoid it, and
the grafts do not encounter each other in their passage through
the bones. The elbow joint is completely locked by the two
osteotomes.
Withdraw the rst osteotome, and replace it by a slightly
thicker one.

Gently rock the osteotome back and forth to create a space


AFTERTREATMENT

With the elbow at a right angle and


the forearm in neutral rotation, a cast is applied from the
axilla to the palm and is bivalved to allow for swelling.
After 2 weeks, the sutures are removed, and a new, snugly
tting cast is applied. A leather lacer corset extending from
the upper arm to the heads of the metacarpal bones and
reinforced by steel bars is tted 8 weeks after surgery. This
is worn until osseous union occurs.
Brittain described arthrodesis of the elbow by two tibial
grafts crossed in the shape of the letter X to lock the
joint (Fig. 4-14). No important anatomical structures are
encountered in this procedure, although care must be taken
that the second graft, which is introduced posteriorly, does
not project too far anteriorly. Brittain pointed out that
considerable latitude is possible because with the elbow in
exion the vessels and nerves in the cubital fossa are displaced forward.
Koch and Lipscomb reported 17 attempted elbow
arthrodeses using a variety of techniques, only 8 of which
were successful. All 5 arthrodeses performed with a modication of the Brittain technique were successful.

Ch004-A03329.indd 220

for the graft. Introduce the graft with bone forceps, engage it
for 1.3 cm or more, and drive it into place.

Fig. 4-14 Arthrodesis of elbow: Brittain technique, with


cortical grafts crossed at center of joint. (Modied from
Brittain HA: Architectural principles in arthrodesis, Edinburgh, 1942,
E&S Livingstone.)

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Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

Introduce the second graft in the same way. The bone may
crack to some extent when tting the grafts in tightly. Severe
cracking is prevented, however, by drilling the holes. Introduction
of both grafts, either from below through the olecranon or from
above through the humerus through a smaller incision, should
not be attempted because the bone would splinter; the larger
exposure is justied.

AFTERTREATMENT

Aftertreatment is the same as for


Technique 4-7.
Staples devised a technique for arthrodesis of the elbow
in which a relatively extensive bony surface is exposed for
contact with an iliac graft and xed to the humerus and
ulna by screws.
TECHNIQUE 4-9

Staples

221

Pack iliac bone chips into the joint and apply an iliac graft to
the posterior surface of the humerus and the proximal surface of
the ulna. Anchor the graft above with one screw.
Replace the olecranon process, and fasten it with a second
screw that passes through the olecranon and the lower end of
the graft and into the upper end of the ulna.

AFTERTREATMENT

Aftertreatment is the same as for


Technique 4-7.
Arales reported success in 11 patients with tuberculosis
of the elbow using a technique combining resection of the
radial head, dbridement, and synovectomy with insertion
of the triangle-shaped olecranon into a corresponding hole
in the humerus and xing it with a screw (Fig. 4-16). A
bone graft is not used. Arales recommends anterior transposition of the ulnar nerve at the time of fusion.

Approach the elbow through a posterior longitudinal incision,


and isolate and retract the ulnar nerve.

Osteotomize the olecranon as shown in Figure 4-15.


Split the triceps tendon medially and laterally, and raise it
proximally as a ap, along with the attached fragment of the
olecranon.

Denude the elbow joint of cartilage, and cut the distal


posterior surface of the humerus down to a at surface in line
with the surface of the remaining proximal end of the ulna.

TECHNIQUE 4-10

Arales

Position the patient prone with the elbow exed over a


padded support.

Make a straight posterior incision over the midline of the


olecranon extending 7 cm distally and proximally.

Expose the ulnar nerve, and protect it with Penrose drains (Fig.
4-16A).

Fig. 4-15 Staples arthrodesis of elbow. A, Incision. B, Tip of olecranon osteotomized to form
bed for graft. Ulnar nerve is protected. C, Graft xed to humerus and ulna. (Modied from
Staples OS: Arthrodesis of the elbow joint, J Bone Joint Surg 34A:207, 1952.)

Ch004-A03329.indd 221

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Part II Arthrodesis

olecranon (Fig. 4-16B). Modify the angulation of the hole to


permit the desired degree of exion of the elbow. Insert the
triangular olecranon peg into the fashioned hole of the humerus,
and trim away the excess bone to leave a projection of a few
millimeters (Fig. 4-16C) on the medial and lateral epicondyles to
eliminate sharp prominences under the skin aps.

Remove any remaining cartilage, and use the resected


epicondylar and olecranon fragments as bone grafts to ll any
cavities.

Insert a bone screw obliquely through the humerus into the


ulna in a medial or lateral direction, overdrilling the humeral
cortex to allow a lag effect of the screw (Fig. 4-16D).

Close the triceps tendon with strong, interrupted sutures.


Transpose the ulnar nerve anteriorly into a subcutaneous
position. Establish hemostasis, and close the wound in layers.

Fig. 4-16 Technique for fusion in tuberculous arthritis of


elbow. A, Isolation of ulnar nerve, splitting and release of
triceps tendon from olecranon, and posterior synovectomy.
B, Excision of radial head and anterior synovectomy; shaping
of olecranon, and creation of triangular hole through distal
end of humerus. C, Insertion of olecranon through hole in
distal end of humerus, screw xation, medial and lateral
epicondylectomy, and anterior transposition of ulnar nerve.
Resulting bone chips are used to ll any gaps around stump
of olecranon. D, Lateral view of completed fusion showing
xation screw in place. (Redrawn from Arales RP: A new
technique of fusion for tuberculous arthritis of the elbow, J Bone
Joint Surg 63A:1396, 1981.)

AFTERTREATMENT

The elbow is immobilized in a longarm cast for 3 months and in a removable splint for another
month. Hand and shoulder exercises are begun soon after
surgery.
The AO group has recommended combined internal
and external xation for arthrodesis of the elbow. In this
technique, an external compression device is used with a
cancellous screw securing the olecranon to the distal humerus.
We have had no experience with this technique, but it
might offer advantages, especially in posttraumatic elbow
infection.

TECHNIQUE 4-11
TECHNIQUE 4-10

Aralescontd

Split the triceps tendon down to synovial tissue and to the


attachment of the tendon to the olecranon.

Strip the periosteum distally from the olecranon and proximal


ulna medially and laterally for 5 cm.

Perform a posterior synovectomy and detach the origins of the

Mller et al.

Expose the elbow posteriorly as described in previous


techniques.

Resect all cartilage and synovium from the olecranon and


distal humerus.
Fashion a squared-off shelf in the proximal ulna, and resect
the distal end of the humerus to t it (Fig. 4-17).

common exor and extensor muscles from the medial and lateral
epicondyles.

Resect the radial head at the level of the biceps tuberosity.

Dislocate the ulnohumeral joint, and free the distal 5 to 7 cm

canal of the humerus to stabilize the arthrodesis temporarily in


the desired position. Insert a Steinmann pin transversely through
the olecranon in line with the anterior cortex of the humerus.
Remove the transxing medullary pin, and replace it with a
cancellous screw and washer. Insert another transverse
Steinmann pin through the humerus, and use an external xator
to apply compression across the arthrodesis.

of the distal humerus of its soft-tissue attachments.

Excise the radial head proximal to the biceps tuberosity, and


perform an anterior synovectomy.
With a saw, trim the olecranon into a triangular stump.
Use a drill, rongeur, and osteotome to fashion a triangular
hole through the olecranon fossa of the humerus to receive the

Ch004-A03329.indd 222

Insert a Steinmann pin from the olecranon into the medullary

Close the wound in layers over drains.

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Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

TECHNIQUE 4-12

Spier

Expose the elbow posteriorly as described previously, dbride


the joint, and resect the radial head at the level of the biceps
tuberosity.

Osteotomize the olecranon and humerus to t as in the AO


technique (Technique 4-5).
Contour an 8-hole to 12-hole AO plate to achieve the desired
degree of exion at the elbow, and secure it to the humerus
posteriorly by the standard AO technique.

Fig. 4-17 Mller et al. technique of elbow arthrodesis (see


text). (Redrawn from Mller ME, Allgower M, Willenegger H:
Manual of internal xation: techniques recommended by the AO group,
ed 2, Berlin, 1979, Springer-Verlag.)

Secure a tensioning device to the ulna and the distal end of


the plate, and apply compression to the arthrodesis site. Secure
the plate to the ulna with screws in the standard fashion (Fig.
4-18). Accessory cancellous screws may be used for additional
stability if needed.
Apply bone graft around the fusion as necessary, and close
the wound in layers over drains.

AFTERTREATMENT

The xator and pins are removed at


6 to 8 weeks, and a long-arm cast is worn until the arthrodesis is solid clinically and radiographically.
Spier reported successful fusion in four patients using
internal xation with a broad AO type of plate bent to
90 degrees. He also recommends resection of the radial
head and osteotomy of the humerus and olecranon to t
in a manner similar to the AO technique. In 1992,
McAuliffe et al. reported 15 elbow arthrodeses using the
AO compression plate technique. The most common
indication was a high-energy, open, infected injury with
associated bone loss. Arthrodesis was successful in all but
one elbow, in which a severe, deep infection necessitated
amputation.

B
Fig. 4-18

Ch004-A03329.indd 223

AFTERTREATMENT

A long-arm cast is applied. The


sutures are removed at 2 weeks, and the cast is changed.
Support is continued until the arthrodesis is solid. The
plate and screws should not be removed earlier than 1 year
after surgery.

Complications
Complications of elbow arthrodesis include neurovascular
injury, wound infection, delayed union, nonunion, and
malunion. Painful prominent hardware and skin break-

C
AC, Spier arthrodesis of elbow.

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Part II Arthrodesis

down can occur over the posterior aspect of the elbow


where subcutaneous tissue is minimal. Repeat surgery for
painful hardware is common. We recommend waiting at
least 18 months after radiographic fusion before considering
hardware removal. The elbow should be protected with a
brace or cast for several weeks after hardware removal to
prevent fracture.

WRIST ARTHRODESIS
History
Because of the trend toward reconstructive surgery, arthrodesis of the wrist is performed less often now than it was
a few decades ago. It still remains an important procedure,
however, in the armamentarium of the orthopaedic surgeon.
Arthrodesis of the radiocarpal joint has evolved over the
last 50 years. The trend has been toward increasing stability
in the method of xation. Early procedures used cortical
or cancellous bone grafting with limited xation methods,
such as pins or screws. Campbell and Keokarn described
an inlay bone grafting technique of wrist fusion in 1964.
Haddad and Riordan applied this technique through a
lateral (radial) approach.
Various xation methods have been described, including
screws, multiple staples, and multiple Steinmann pins.
These methods still are employed frequently, especially in
patients with rheumatoid arthritis. Even in these patients,
however, the trend has been toward plate xation for wrist
arthrodesis. Rehak et al. compared the results of pin versus
plate xation in 57 patients with rheumatoid arthritis.
Successful results were not signicantly different in the two
groups.
In 1970, the AO group described a rigid xation method
using a dynamic compression plate. In mechanical testing
studies, this plate proved to be the most stable xation and
currently is the most favored and commonly used technique for wrist arthrodesis. The advantages of the dynamic
compression plate include excellent fusion rates, decreased
incidence of malposition, and increased stability that allows
early rehabilitation. The AO plating technique requires less
bone grafting than other methods, and often an adequate
amount of graft can be harvested from the distal radius.
Anderson and Thomas reported the use of dynamic compression plates for wrist arthrodesis without the use of bone
graft. All 15 patients in their series achieved wrist fusion
by 12 weeks. We recommend using iliac crest bone graft
unless an adequate amount of cancellous graft is available
from locally resected bone and the distal radius.

Indications
Posttraumatic arthritis with painful destruction of the joint
is a common indication for wrist fusion, especially in the

Ch004-A03329.indd 224

Box 4-4 Indications for Wrist Arthrodesis


Posttraumatic arthritis
Neoplastic lesions
Severely comminuted intraarticular fractures
Rheumatoid arthritis
Wrist or hand paralysis
Spastic hemiplegia
Failed total joint arthroplasty
Failed limited arthrodesis

dominant wrist of a manual laborer. Some authors have


recommended immediate wrist fusion for irreparable
intraarticular fractures of the distal radius. Other indications include joint destruction caused by infection or tumor
resection, Kienbck disease, rheumatoid arthritis, stabilization of a paralytic wrist and hand, correction of wrist
exion deformity in patients with spastic hemiplegia, and
failed total wrist arthroplasty. A failed previous limited
arthrodesis is another indication (Box 4-4).
Contraindications include an open physis of the distal
radius. The distal radial physis does not close until approximately 17 years of age, and care should be taken not to
damage it in patients younger than age 17. After partial
destruction of the physis by disease or trauma, however,
the remaining part may be excised to prevent unequal
growth. Fusion of the wrist in children is difcult to secure
because of the preponderance of cartilage in the joint.
When practical, the procedure should be postponed until
the patient is 10 to 12 years of age. Wrist arthrodesis is
not recommended in an elderly patient with a sedentary
lifestyle, especially if the nondominant wrist is involved,
such as in a patient with rheumatoid arthritis for whom
tendon transfer or joint replacement may be more
appropriate.

Position
The wrist should be fused in a position that would not be
fatiguing and that would allow maximum grasping strength
in the hand. This is usually 10 to 20 degrees of extension
(dorsiexion) with the long axis of the third metacarpal
shaft aligned with the long axis of the radial shaft. Clinically,
it is determined by the position that the wrist normally
assumes with the st strongly clenched. Several authors
recommend the neutral position, which allows full supination and pronation and personal hygiene functions, while
providing sufcient grasping strength. Still others favor
slight palmar exion to 25 degrees. In general, neutral to
5 degrees of ulnar deviation is preferred. If bilateral wrist
fusions are indicated, the positions of the wrists should be
determined by the needs of the patient. The neutral position for both wrists is thought to provide maximal
function.

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Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

Surgical Techniques
Of the many techniques that have been described, most
include the use of a bone graft. The iliac crest is the most
common donor site, but bone graft may be obtained from
the distal radius, ulna, tibia, or rib.
Sorial et al. reported successful fusion in 18 patients with
the use of a radial sliding graft xed with a dynamic compression plate. In some patients, the graft bridged from the
radius to the proximal carpal bones, and in others it
extended distally to the base of the third metacarpal.
Haddad and Riordan recommended that the second and
third carpometacarpal joints always be included in the
fusion to prevent development of arthritis and resultant
painful motion. The disease of the wrist frequently extends
into these joints, making complete fusion necessary. If the
carpometacarpal joints are preserved, however, motion can
be maintained or even increased in these joints if they are
not denuded. Nagy and Bchler reported 81 wrist arthrodeses, 47 of which also included the third carpometacarpal
joint. Forty-three percent (20 patients) developed a painful
nonunion, and 23% (11 patients) required repeat surgery
to treat the third carpometacarpal joint. Only one patient
of the 34 in whom the third carpometacarpal joint was left
alone had postoperative pain at the third carpometacarpal
joint.
The AO technique (recommended by Heim and Pfeiffer
and more recently by Wright and McMurtry) provides
excellent internal xation, eliminating the necessity for
prolonged immobilization. A titanium low-prole dynamic
compression plate (Synthes) designed by the AO Hand
Study Group also can be used (Fig. 4-19). The straight
plate is employed when a large intercalary graft is required
for a traumatic or tumorous defect. The short carpal bend
is used in small wrists and wrists in which the proximal

row has been resected. The longer carpal bend is used in


large wrists. All three of the plates have tapered edges and
are lled with recessed screw heads to avoid excess prominence. These plates tend to cause less postoperative hardware pain, but still have to be removed approximately 15%
of the time. They also are signicantly more expensive,
costing approximately twice as much as a standard 3.5-mm
dynamic compression plate.
In a mechanical testing study by Morelli et al., dynamic
compression plate xation was shown to be superior to
Steinmann pins. There were no differences found in the
stability of the standard 3.5-mm plate and the precontoured
low-prole plates.

Plate Fixation
The following technique describes the use of precontoured
low-contact plates through a dorsal approach to the wrist.
In the absence of these plates, an eight-hole or nine-hole,
3.5-mm reconstruction or dynamic compression plate can
be used. In this case, the plate must be contoured intraoperatively to t the dorsal wrist.
TECHNIQUE 4-13

AO Group

Make a curvilinear skin incision beginning 2 cm and extending


in an ulnar direction over the distal radioulnar joint and ending
over the midshafts of the second and third metacarpals.
Identify and protect the branches of the supercial cutaneous
nerve.
Make a longitudinal incision between the tendons of the
extensor digitorum communis, which are retracted in an ulnar
direction, and the extensor pollicis longus, which is retracted in
the radial direction.

Make an I-shaped incision in the capsule, crossing proximally


over the radiocarpal joint and distally over the carpometacarpal
joints.
Using an osteotome, remove Listers tubercle and the dorsal
cortices of the carpal bones to allow at apposition of the
precontoured plate.
Denude the radiocarpal and intercarpal joint surfaces of
cartilage, and ll the gaps with cancellous bone harvested from
the excised bone and distal radial metaphysis.

Fig. 4-19 Three types of AO wrist arthrodesis plates: straight


plate, long carpal bend, and short carpal bend. All use three
2.7-mm metacarpal screws, one 2.7-mm capitate screw, and
four 3.5-mm radius screws. (From Hastings H II: Wrist [radiocarpal] arthrodesis. In Green DP, Hotchkiss RN, Pederson WC,
eds: Greens operative hand surgery, ed 4, New York, 1999, Churchill
Livingstone.)

Ch004-A03329.indd 225

A 3.5-mm cortex lag screw may be placed through the radial


styloid into the capitate to pull the carpus against the radial
styloid and help prevent impingement of the distal radioulnar
joint.
Secure the appropriate precontoured plate to the dorsal aspect
of the third metacarpal. It is important to ensure that the distal
end of the plate is centered on the metacarpal.
Mark the position of the distal hole, and remove the plate.

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Part II Arthrodesis

TECHNIQUE 4-13 AO Groupcontd


Under direct view, drill a 2-mm hole in a dorsal-to-volar
direction, centered in the midline of the metacarpal. Replace
the plate, measure, tap, and ll the distal hole with a 2.7-mm
screw.
Fill the remaining metacarpal holes, and compress the
radiocarpal and intercarpal joints. This is done using a 3.5-mm
screw placed in compression mode through the second-most
distal hole in the radius (Figs. 4-20 and 4-21). Fill the remaining
holes, and close the capsule over a small suction drain.

AFTERTREATMENT

A cast is applied from the upper arm


to the tips of the ngers and thumb, with the elbow at a
right angle, the forearm in neutral position, and the wrist
in 10 to 15 degrees of extension. The ngers and thumb
are slightly exed. To allow for swelling, the dorsum of
the cast is windowed. At 3 weeks, a short cast, below the
elbow to just proximal to the metacarpophalangeal joints,
is applied with the wrist in the correct position. Support
is continued until rm fusion is present, usually at 10 to
12 weeks.

Fusion with Proximal Row Carpectomy


Louis et al. described using a technique combining proximal row carpectomy with radiocapitate fusion that was
successful in 11 patients. One patient developed subsequent

Fig. 4-21

Lateral view of wrist fusion with AO plate.

arthritis of the second and third carpometacarpal joints and


required later fusion.

TECHNIQUE 4-14

Louis et al.

Approach the wrist dorsally as described in Technique 4-13.


Remove approximately 80% of the proximal scaphoid, a
portion of the hamate, and the entire triquetrum and lunate (Fig.
4-22). Retain a portion of the scaphoid and hamate to prevent
distal carpal row migration.
Denude the articular cartilage from the distal radius and
proximal capitate.

The fusion site may be supported with Kirschner wires or


staples and bone graft as necessary.

AFTERTREATMENT

The wrist is immobilized in a cast or


splint for 12 to 16 weeks. The radial or lateral approach
allows placement of the bone graft without disturbing the
bed of the extensor tendons.
Fig. 4-20 Dorsal view of wrist fusion with AO wrist fusion
plate (low-contact dynamic compression plate). (Redrawn
from: Hastings H II: Wrist [radiocarpal] arthrodesis. In Green
DP, Hotchkiss RN, Pederson WC, eds: Greens operative hand
surgery, ed 4, New York, 1999, Churchill Livingstone.)

Ch004-A03329.indd 226

Cortical Strut Autograft


Haddad and Riordan described a technique of arthrodesis
of the wrist through a radial or lateral approach. They
believed that the formation of scar with the dorsal approach

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Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

Divide the extensor carpi radialis longus tendon just proximal


to its insertion on the base of the second metacarpal, leaving a
stump distally so that it can be sutured later.

Remove the capsule from the radiocarpal, the intercarpal, and


the second carpometacarpal joints.
Locate the dorsal branch of the radial artery, and ligate and
divide its dorsal branch to the dorsal carpal arch.
Denude the radiocarpal joint of articular cartilage and
subchondral bone.
Using an electric saw, obtain from the medial table of the iliac
crest a graft about 2.5 cm wide 4 cm long.

A, Schematic diagram depicts bone to be resected


to accomplish capitate-radius arthrodesis. B, Schematic of
postoperative capitate-radius arthrodesis. Proximal pole of
capitate and distal surface of radius have been denuded of
cartilage and subchondral bone. Portal has been established
in distal radius, and two congruous trabecular surfaces have
been apposed. (Redrawn from Louis DS, Hankin FM, Bowers
WH: Capitate-radius arthrodesis: an alternative method of radiocarpal arthrodesis, J Hand Surg 9A:365, 1984.)
Fig. 4-22

With the wrist in 15 degrees of dorsiexion, cut a slot, still


using an electric saw, in the distal end of the radius, the carpal
bones, and the bases of the second and third metacarpals. Do
not cut through the medial cortex of the radius and enter the
distal radioulnar joint. Place the graft in the prepared bed (Fig.
4-23).
If the wrist is unstable, insert a nonthreaded Kirschner wire
obliquely or longitudinally to engage the base of the second
metacarpal and the distal radius. Cut off the wire under the skin
at the palm, to be removed 6 to 8 weeks later.

led to more restricted tendon gliding. Their technique has


several advantages. The distal radioulnar joint is not entered,
the extensor tendons to the digits are not disturbed as
much, and because dorsal thickening is avoided, the appearance of the wrist is not altered. Haddad and Riordan
reported only one failure in 24 wrists using this
technique.
Carlson and Simmons reported successful results of 12
wrist arthrodeses using a cortical graft and a Steinmann
pin after failure of wrist implant arthroplasty. Seven of the
patients had a good or excellent result using bulk fresh
frozen femoral head allograft instead of iliac crest
autograft.
TECHNIQUE 4-15 Haddad and Riordan
Begin a J-shaped skin incision 2.5 to 4 cm proximal to the
radial styloid on the midlateral aspect of the forearm, extend it
distally across the styloid, and then curve it dorsally to end at the
base of the second metacarpal.
Mobilize and retract the supercial branch of the radial nerve,
usually in the palmar direction.
Identify the interval between the rst and second dorsal
compartments, and incise the dorsal carpal ligament in this
interval, leaving it attached to the volar aspect of the radius.

Mobilize subperiosteally, and retract the abductor pollicis


longus, extensor pollicis brevis, and the wrist and nger
extensors.

Ch004-A03329.indd 227

Fig. 4-23 Haddad and Riordan arthrodesis of wrist. A,


Radial view showing slot cut in distal radius, carpal bones,
and bases of second and third metacarpals. B, Dorsal view
showing shape of graft and its nal position (broken line) in
slot. (From Haddad RJ Jr, Riordan DC: Arthrodesis of the wrist:
a surgical technique, J Bone Joint Surg 49A:950, 1967.)

5/31/2007 12:12:46 PM

228

Part II Arthrodesis

TECHNIQUE 4-15 Haddad and Riordancontd


Close the dorsal carpal ligament deep to the abductor pollicis
longus and extensor pollicis brevis.
Suture the extensor carpi radialis longus tendon and close the
wound over a drain.

AFTERTREATMENT

Aftertreatment is the same as for the

AO technique.

Box 4-5 Complications of Wrist


Arthrodesis
Painful hardware
Tendon adhesions/ruptures
Early wound infection/dehiscence
Distal radioulnar joint pain/instability
Metacarpophalangeal joint stiffness
Carpal tunnel syndrome
Reex sympathetic dystrophy
Nonunion
Persistent pain

Kirschner Wire Fixation


Watson and Vendor reported a technique using a radial
incision and incorporating iliac bone graft into the fusion
site and securing it in place with two or more removable
Kirschner wires. This technique should be considered in
patients with poor soft-tissue and bone quality, as often
found in inammatory arthritis.
TECHNIQUE 4-16 Watson and Vendor
Make a longitudinal incision radially extending from the distal
6 cm of the radius to the distal second metacarpal.

Protect the supercial radial nerve and deep branch of the


radial artery.
Free and retract the extensor pollicis brevis and abductor
pollicis longus in the palmar direction. Retract the extensor
pollicis longus and extensor carpi longus and brevis.

Lift the origin of the rst dorsal interosseous from the second
metacarpal.
Fashion a groove extending from 2 cm of the distal radius to
1 cm of the second and third metacarpals by drilling multiple
holes and connecting them with rongeurs. This trough should
include the scaphoid, capitate, lunate, and trapezoid. The depth
of the groove should be just through the metacarpals and even
throughout.

Place an outer cortical piece of iliac bone graft into the trough
with the cancellous side down.

Lock the graft into place by bringing the wrist from ulnar
deviation to the neutral position, and secure it into position by
passing 0.045-inch Kirschner wires through the distal radius and
graft proximally and the metacarpals and graft distally.

An ulnar approach also has been described in which the


dorsal or radial tissues are compromised. In conjunction
with many other useful procedures for rheumatoid arthritis
of the upper extremity, Smith-Petersen reported a method
of fusing the wrist, suggested by the exposure of the wrist
after resection of the distal end of the ulna. This technique
should not be used unless there is disease or derangement
of the distal radioulnar joint because the procedure uses the
distal ulna as a bone graft inserted between the radius and
the carpus. No matter what the indication is for arthrodesis, if the distal radioulnar joint or ulnocarpal joint is free
of disease, it should be spared from fusion.

Complications
Complications of wrist arthrodesis are listed in Box 4-5.
Immediate complications of wrist arthrodesis include
damage to the supercial radial nerve and hematoma,
which can lead to skin loss and possible infection, especially
when a dorsal approach is used. Acute carpal tunnel syndrome also is frequently reported. Delayed complications
include scarring of the extensor tendons to the digits,
metacarpophalangeal joint stiffness, carpal tunnel syndrome, and reex sympathetic dystrophy. Painful hardware
is the most common cause for reoperation after wrist fusion.
All patients should be advised preoperatively that the hardware likely will need to be removed. Nonunion is rare.
Arthritis also may develop in the distal radioulnar joint,
ulnocarpal joint, or carpometacarpal joints if these joints
are not incorporated in the fusion mass at the time of
surgery. Chronic unexplained pain occurs in 10% of
patients after wrist arthrodesis.

References
AFTERTREATMENT

The postoperative splint is replaced at


1 week by a long-arm cast incorporating the thumb, index,
and long ngers. This cast is replaced at 4 weeks by a
short-arm splint, which is used for an additional 2 to 4
weeks. The Kirschner wires are removed when the fusion
site is solid.

Ch004-A03329.indd 228

Shoulder
Arntz CT, Matsen FA, Jackins S: Surgical management of
complex irreparable rotator cuff deciency, J Arthroplasty 6:363,
1991.
Bayley JIL, Kessel L: The Kessel total shoulder replacement. In
Bayley I, Kessel L, eds: Shoulder surgery, New York, 1982,
Springer-Verlag.

5/31/2007 12:12:48 PM

Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

Beltran JE, Trilla JC, Barjau R: A simplied compression


arthrodesis of the shoulder, J Bone Joint Surg 57A:538, 1975.
Brett AL: A new method of arthrodesis of the shoulder joint,
incorporating the control of the scapula, J Bone Joint Surg
15:969, 1933.
Brittain HA: Architectural principles in arthrodesis, ed 2, Edinburgh,
1952, E&S Livingstone.
Carnesale PG, Stewart MJ: Complications of arthrodesis surgery.
In Epps CH Jr, ed: Complications in orthopaedic surgery, ed 3,
Philadelphia, 1994, Lippincott.
Carroll RE: Wire loop in arthrodesis of the shoulder, Clin Orthop
9:185, 1957.
Chammas M, Goubier JN, Coulet B, et al: Glenohumeral
arthrodesis in upper and total brachial plexus palsy: a comparison of functional results, J Bone Joint Surg 86B:692, 2004.
Chandler RW: Glenohumeral arthrodesis, Tech Orthop 3:65,
1989.
Charnley J: Compression arthrodesis of the ankle and shoulder,
J Bone Joint Surg 33B:180, 1951.
Charnley J, Houston JK: Compression arthrodesis of the shoulder, J Bone Joint Surg 46B:614, 1964.
Cheng EY, Gebhardt MC: Allograft reconstructions of the shoulder after bone tumor resections, Orthop Clin North Am 22:37,
1991.
Clare DJ, Wirth MA, Groh GI, et al: Current concepts review:
shoulder arthrodesis, J Bone Joint Surg 83A:593, 2001.
Coeld RH: Shoulder arthrodesis and resection arthroplasty, Instr
Course Lect 34: 268, 1985.
Coeld RH: Arthrodesis and resectional arthroplasty of the
shoulder. In Evarts CM, ed: Surgery of the musculoskeletal system,
ed 2, New York, 1990, Churchill Livingstone.
Coeld RH, Briggs BT: Glenohumeral arthrodesis: operative
and long-term functional results, J Bone Joint Surg 61A:668,
1979.
Damron TA, Rock MG, OConnor MI, et al: Functional laboratory assessment after oncologic shoulder joint resectors, Clin
Orthop Relat Res 348:124, 1998.
Davis JB, Cottrell GW: A technique for shoulder arthrodesis, J
Bone Joint Surg 44A:657, 1962.
Diaz JA, Cohen SB, Warren RF, et al: Arthrodesis as a salvage
procedure for recurrent instability of the shoulder, J Shoulder
Elbow Surg 12:237, 2003.
Emmelot CH, Nielsen HKL, Eisma WH: Shoulder fusion for
paralyzed upper limb, Clin Orthop Relat Res 340:95, 1997.
Gill AB: A new operation for arthrodesis of the shoulder, J Bone
Joint Surg 13:287, 1931.
Gill TJ, Warren RF, Rockwood CA, et al: Complications in
shoulder surgery, Instr Course Lect 48:359, 1999.
Gonzalez-Diaz R, Rodriguez-Merchan EC, Gilbert MS: The
role of shoulder fusion in the era of arthroplasty, Int Orthop
21:204, 1997.
Groh GI, Williams GR, Jarman RN, et al: Treatment of complications of shoulder arthrodesis, J Bone Joint Surg 79A:881,
1997.
Hawkins RJ, Neer CS II: A functional analysis of shoulder
fusions, Clin Orthop Relat Res 223:65, 1987.
Ingram AJ, Miller TR: Arthrodesis of the shoulder, Memphis, Tenn,
1950 (unpublished).
Johnson CA, Healy WL, Brooker AF Jr, et al: External xation
shoulder arthrodesis, Clin Orthop Relat Res 211:219, 1986.
Jonsson E, Lidgren L, Rydholm U: Position of shoulder arthrodesis measured with moir photography, Clin Orthop Relat Res
238:117, 1989.
Kocialkowski A, Wallace WA: Shoulder arthrodesis using an
external xator, J Bone Joint Surg 73B:180, 1991.

Ch004-A03329.indd 229

229

Kostuik JP, Schatzker J: Shoulder arthrodesisfamily variant


A.O. technique. In Bateman JE, Welsh RP, eds: Surgery of the
shoulder, Toronto, 1984, Mosby.
Kumar VP, Satku SK, Mitra AK, et al: Function following
limb salvage for primary tumors of the shoulder girdle: 10
patients followed 4 (111) years, Acta Orthop Scand 65:55,
1994.
Lettin A: Shoulder replacement in rheumatoid arthritis, Reconstr
Surg Traumatol 18:55, 1981.
Mah JY, Hall JE: Arthrodesis of the shoulder in children, J Bone
Joint Surg 72A:582, 1990.
Makin M: Early arthrodesis for a ail shoulder in young children,
J Bone Joint Surg 59:317, 1977.
May VR Jr: Shoulder fusion: a review of fourteen cases, J Bone
Joint Surg 44A:65, 1962.
Miller BS, Harper WP, Gillies RM, et al: Biomechanical analysis
of ve xation techniques used in glenohumeral arthrodesis,
Aust N Z J Surg 73:1015, 2003.
Mitsunaga MM, Jones DA, Parkinson D: Arthrodesis of the
paralytic shoulder in children, Orthop Trans 11:186, 1987
(abstract).
Mohammed NSE-S: A simple method of shoulder arthrodesis, J
Bone Joint Surg 80B:620, 1998.
Morgan CD, Casscells CD: Arthroscopic-assisted glenohumeral
arthrodesis, Arthroscopy 8:262, 1992.
Moseley HF: Arthrodesis of the shoulder in the adult, Clin Orthop
20:156, 1961.
Mller ME, Allgower M, Willenegger H: Manual of internal xation: techniques recommended by the AO group, Berlin, 1979,
Springer-Verlag.
Nagano A, Okinaga S, Ochiai N, et al: Shoulder arthrodesis by
external xation, Clin Orthop Relat Res 247:97, 1989.
Nagy L, Koch PP, Gerber C: Functional analysis of shoulder
arthrodesis, J Shoulder Elbow Surg 13:386, 2004.
OConnor MI, Sim FH, Chao EYS: Limb salvage for neoplasms
of the shoulder girdle: intermediate reconstructive and functional results, J Bone Joint Surg 78A:1872, 1996.
Oppenheim WL, Lewis K, Jinnah R: Shoulder arthrodesis for
neuromuscular impairment in children, Orthop Trans 11:109,
1987 (abstract).
Pruitt DL, Hulsey RE, Fink B, et al: Shoulder arthrodesis in
pediatric patients, J Pediatr Orthop 12:640, 1992.
Putti V: Arthrodesis for tuberculosis of the knee and of the
shoulder, Chir Organi Mov 18:217, 1933.
Richards RR, Sherman RMP, Hudson AR, et al: Shoulder
arthrodesis using a pelvic-reconstruction plate: a report of
eleven cases, J Bone Joint Surg 70A:416, 1988.
Rouholamin E, Wootton JR, Jamieson AM: Arthrodesis of the
shoulder following brachial plexus injury, Injury 22:271,
1991.
Rowe CR: Re-evaluation of the position of the arm in arthrodesis
of the shoulder in the adult, J Bone Joint Surg 56A:913, 1974.
Rowe CR: Arthrodesis of the shoulder used in treating painful
conditions, Clin Orthop Relat Res 173:92, 1983.
Rhmann O, Kirsch L, Buch S, et al: Primary stability of shoulder arthrodesis using cannulated cancellous screws, J Shoulder
Elbow Surg 14:51, 2005.
Rhmann O, Schmolke S, Bohnsack M, et al: Shoulder arthrodesis: indications, technique, results, and complications, J
Shoulder Elbow Surg 14:38, 2005.
Rybka V, Raunio P, Vainio K: Arthrodesis of the shoulder in
rheumatoid arthritis: a review of forty-one cases, J Bone Joint
Surg 61B:155, 1979.
Schroder HA, Frandsen PA: External compression arthrodesis of
the shoulder joint, Acta Orthop Scand 54:592, 1983.

5/31/2007 12:12:48 PM

230

Part II Arthrodesis

Sjostrom L, Mjoberg B: Suprascapular nerve entrapment in the


arthrodesed shoulder, J Bone Joint Surg 74B:470, 1992.
Sperling JW, Coeld RH: Total shoulder arthroplasty after
attempted shoulder arthrodesis: report of three cases, J Shoulder
Elbow Surg 12:302, 2003.
Stark DM, Bennett JM, Tullos HS: Rigid internal xation for
shoulder arthrodesis, Orthopedics 14:849, 1991.
Steindler A: Arthrodesis of the shoulder, AAOS Instr Course Lect
2:293, 1944.
Uematsu A: Arthrodesis of the shoulder: posterior approach, Clin
Orthop Relat Res 139:169, 1979.
Vastamaki M: Shoulder arthrodesis for paralysis and arthrosis,
Acta Orthop Scand 58:549, 1987.
Watson-Jones R: Extra-articular arthrodesis of the shoulder, J
Bone Joint Surg 15:862, 1933.
White JI, Hoffer MM, Lehman M: Arthrodesis of the paralytic
shoulder, J Pediatr Orthop 9:684, 1989.
Wick M, Mller EJ, Ambacher T, et al: Arthrodesis of the shoulder after septic arthritis: long-term results, J Bone Joint Surg
85B:666, 2003.
Wilde AH, Brems JJ, Boumphrey FR: Arthrodesis of the shoulder: current indications and operative technique, Orthop Clin
North Am 18:463, 1987.
Elbow
Arales RP: A new technique of fusion for tuberculous arthritis
of the elbow, J Bone Joint Surg 63A:1396, 1981.
Brittain HA: Architectural principles in arthrodesis, Edinburgh, 1942,
E&S Livingstone.
Burkhalter W: Arthrodesis of the salvage elbow, Orthopedics
9:733, 1986.
Hallock H: Fusion of the elbow joint for tuberculosis, J Bone Joint
Surg 14:195, 1932.
Koch M, Lipscomb PR: Arthrodesis of the elbow, Clin Orthop
Relat Res 50:151, 1967.
Lerner A, Stein H, Calif E: Unilateral hinged external xation
frame for elbow compression arthrodesis: the stepwise attainment of a stable 90-degree exion position: a case report, J
Orthop Trauma 19:52, 2005.
McAuliffe JA, Burkhalter WE, Ouellette EA, et al: Compression
plate arthrodesis of the elbow, J Bone Joint Surg 74B:300,
1992.
Mller ME, Allgower M, Schneider R, et al: Manual of internal
xation: techniques recommended by the AO group, ed 2, Berlin,
1979, Springer-Verlag.
Nagy SM III, Szabo RM, Sharkey NA: Unilateral elbow arthrodesis: the preferred position, J South Orthop Assoc 8:80, 1999.
ONeill OR, Morrey BF, Tanaka S, et al: Compensatory motion
in the upper extremity after elbow arthrodesis, Clin Orthop
Relat Res 281:89, 1992.
Preshal BP, Chillag KJ: Radiohumeral arthrodesis for salvage of
failed total elbow arthroplasty, J Arthroplasty 10:699, 1995.
Rashkoff E, Burkhalter WE: Arthrodesis of the salvage elbow,
Orthopedics 9:733, 1986.
Spier W: Beitrag zur Technik der Druckarthrodese des
Ellenbogengelenks, Mschr Unfallheilkd 76:274, 1973.
Staples OS: Arthrodesis of the elbow joint, J Bone Joint Surg
34A:207, 1952.
Steindler A: Reconstructive surgery of the upper extremity, New York,
1923, Appleton.
Tang C, Roidis N, Itamura J, et al: The effect of simulated elbow
arthrodesis on the ability to perform activities of daily living,
J Hand Surg 26A:1146, 2001.
Young JH: Implications of elbow arthrodesis for individuals with
paraplegia, Phys Ther 73:194, 1993.

Ch004-A03329.indd 230

Wrist
Anderson GA, Thomas BP: Arthrodesis of ail or partially ail
wrists using a dynamic compression plate without bone grafting, J Bone Joint Surg 82B:566, 2000.
Barbier O, Saels P, Rombouts JJ, et al: Long-term functional
results of wrist arthrodesis in rheumatoid arthritis, J Hand Surg
24B:27, 1999.
Beer TA, Turner RH: Wrist arthrodesis for failed wrist implant
arthroplasty, J Hand Surg 22A:685, 1997.
Bolano LE, Green DP: Wrist arthrodesis in post-traumatic arthritis: a comparison of two methods, J Hand Surg 18A:786,
1993.
Brittain H: Architectural principles in arthrodesis, ed 2, London,
1952, E&S Livingstone.
Campbell CJ, Keokarn T: Total and subtotal arthrodesis of
the wrist: inlay technique, J Bone Joint Surg 46A:1520,
1964.
Carlson JR, Simmons BP: Wrist arthrodesis after failed wrist
implant arthroplasty, J Hand Surg 23A:893, 1998.
Clayton ML, Ferlic DC: Arthrodesis of the arthritic wrist, Clin
Orthop Relat Res 187:89, 1984.
Clendenin MB, Green DP: Arthrodesis of the wrist: complications and their management, J Hand Surg 6A:253, 1981.
Craigen MAC, Stanley JK: Distal ulnar instability following
wrist arthrodesis in men, J Hand Surg 20B:155, 1995.
De Smet L, Truyen J: Arthrodesis of the wrist for osteoarthritis:
outcome with a minimum follow-up of 4 years, J Hand Surg
28B:575, 2003.
Evans DM, Ansell BM, Hall MA: The wrist in juvenile arthritis,
J Hand Surg 16B:293, 1991.
Ferlic DC, Jolly SN, Clayton ML: Salvage for failed implant
arthroplasty of the wrist, J Hand Surg 17A:917, 1992.
Fernandez DL: Reconstructive procedures for malunion and
traumatic arthritis, Orthop Clin North Am 24:341, 1993.
Field J, Herbert JJ, Prosser R: Total wrist fusion: a functional
assessment, J Hand Surg 21B:429, 1996.
Haddad RJ Jr, Riordan DC: Arthrodesis of the wrist: a surgical
technique, J Bone Joint Surg 49A:950, 1967.
Hartigan BJ, Nagle DJ, Foley MJ: Wrist arthrodesis with
excision of the proximal carpal bones using the AO/ASIF
wrist fusion plate and local bone graft, J Hand Surg 26B:247,
2001.
Hastings H II: Wrist (radiocarpal) arthrodesis. In Green DP,
Hotchkiss RN, Pederson WC, eds: Greens operative hand surgery,
ed 4, New York, 1999, Churchill Livingstone.
Hastings H II, Weiss AP, Quenzer D, et al: Arthrodesis of the
wrist for post-traumatic disorders, J Bone Joint Surg 78A:897,
1996.
Heim U, Pfeiffer KM: Internal xation of small fractures: technique
recommended by the AO-ASIF group, ed 3, Berlin, 1988,
SpringerVerlag.
Hoffer MM, Zeitzew S: Wrist fusion in cerebral palsy, J Hand
Surg 13A:667, 1988.
Houshian S, Schrder HA: Wrist arthrodesis with the AO titanium wrist fusion plate: a consecutive series of 42 cases, J Hand
Surg 26B:355, 2001.
Howard AC, Stanley D, Getty CJ: Wrist arthrodesis in rheumatoid arthritis: a comparison of two methods of fusion, J Hand
Surg 18B:377, 1993.
Inoue G, Tamura Y: Radiolunate and radioscapholunate arthrodesis, Arch Orthop Trauma Surg 111:333, 1992.
Jebson PJL, Adams BD: Wrist arthrodesis: review of current
techniques, J Am Acad Orthop Surg 9:53, 2001.
Kobus RJ, Turner RH: Wrist arthrodesis for treatment of rheumatoid arthritis, J Hand Surg 15A:541, 1990.

5/31/2007 12:12:48 PM

Chapter 4 Arthrodesis of the Shoulder, Elbow, and Wrist

Kulick RG, DeFiore JC, Straub LR, et al: Long-term results of


dorsal stabilization in the rheumatoid wrist, J Hand Surg
6A:272, 1981.
Lenoble E, Ovadia H, Goutallier D: Wrist arthrodesis using
embedded iliac crest bone graft, J Hand Surg 18B:595,
1993.
Louis DS, Hankin FM, Bowers WH: Capitate-radius arthrodesis:
an alternative method of radiocarpal arthrodesis, J Hand Surg
9A:365, 1984.
Luboshitz S, Burstein G, Engel J: Wrist arthrodesis: modied
Gills technique, J Hand Surg 27B:568, 2002.
Meads BM, Scougall PJ, Hargreaves IC: Wrist arthrodesis
using a Synthes wrist fusion plate, J Hand Surg 28B:571,
2003.
Mikkelsen OA: Arthritis of the wrist in rheumatoid arthritis,
Hand 12:149, 1980.
Mittal RL, Jain NC: Arthrodesis of the wrist by a new technique,
Int Orthop 14:213, 1990.
Moneim MS, Pribyl CR, Garst JR: Wrist arthrodesis: technique
and functional evaluation, Clin Orthop Relat Res 341:23,
1997.
Morelli M, Harris PG, Fowles JV, et al: A mechanical comparison of the immediate stability of three xation devices used in
wrist arthrodesis: a cadaver study, J Hand Surg 24A:828,
1999.
Mller ME, Allgwer M, Willenegger H, eds: Manual of internal
xation, Heidelberg, 1970, Springer-Verlag.
Murphy DM, Khoury JG, Imriglia JE, et al: Comparison of
arthroplasty and arthrodesis for the rheumatoid wrist, J Hand
Surg 28A:570, 2003.
Nagy L, Bchler U: AO-wrist arthrodesis: with and without
arthrodesis of the third carpometacarpal joint, J Hand Surg
27A:940, 2002.
OBierne JO, Boyer MI, Axelrod TS: Wrist arthrodesis using a
dynamic compression plate, J Bone Joint Surg 77B:700, 1995.
Papaioannou T, Dickson RA: Arthrodesis of the wrist in rheumatoid arthritis, Hand 14:12, 1982.
Rayan G: Wrist arthrodesis, J Hand Surg 11A:356, 1986.
Rayan GM, Young BT: Arthrodesis of the spastic wrist, J Hand
Surg 24A:994, 1999.
Reeland AE, Sud V, Jemison DM: Early wrist arthrodesis for
irreparable intraarticular distal radius fractures, Hand Surg
5:113, 2000.
Rehak DC, Kasper P, Boratz ME, et al: A comparison of plate
and pin xation for the rheumatoid wrist, Orthopedics 23:43,
2000.
Richards RR, Patterson SD, Hearn TC: A special plate for
arthrodesis of the wrist: design considerations and biomechanical testing, J Hand Surg 18A:476, 1993.
Richterman I, Weiss AP: Wrist fusion, Hand Clin 13:681, 1997.
Sauerbier M, Kluge S, Bickert B, et al: Subjective and objective
outcomes after total wrist arthrodesis with radiocarpal arthrosis
of Kienbocks disease, Chir Main 19:223, 2000.

Ch004-A03329.indd 231

231

Skak S: Arthrodesis of the wrist by the method of Mannerfelt,


Acta Orthop Scand 53:557, 1982.
Smith-Petersen MN: A new approach to the wrist joint, J Bone
Joint Surg 22:122, 1940.
Sorial R, Tonkin MA, Geschwind C: Wrist arthrodesis using a
sliding radial graft and plate xation, J Hand Surg 19B:217,
1994.
Stanley J, Hullin M: Wrist arthrodesis as a part of composite
surgery of the hand, J Hand Surg 11B:243, 1986.
Stein I: Gill turnabout radial graft for wrist arthrodesis, Surg
Gynecol Obstet 106:231, 1958.
Taleisnik J: Rheumatoid arthritis of the wrist, Hand Clin 5:257,
1989.
Urbaniak JR: Arthrodesis of the hand and wrist. In Evarts CM,
ed: Surgery of the musculoskeletal system, New York, 1990,
Churchill Livingstone.
Vander Griend RA, Funderburk CH: The treatment of giant-cell
tumors of the distal part of the radius, J Bone Joint Surg 75A:899,
1993.
Viegas SF, Rimoldi R, Patterson R: Modied technique of intramedullary xation for wrist arthrodesis, J Hand Surg 14A:618,
1989.
Voutilainen N, Juutilainen T, Ptil H, et al: Arthrodesis of the
wrist with bioabsorbable xation in patients with rheumatoid
arthritis, J Hand Surg 27B:563, 2002.
Watson HK, Goodman ML, Johnson TR: Limited wrist arthrodesis: II. Intercarpal and radiocarpal combinations, J Hand Surg
6A:223, 1981.
Watson HK, Hempton RF: Limited wrist arthrodesis: I. The
triscaphoid joint, J Hand Surg 5A:320, 1980.
Watson HK, Vendor MI: Wrist and intercarpal arthrodesis. In
Chapman MW, ed: Operative orthopedics, Philadelphia, 1993,
Lippincott.
Weideman G, Quenzer D, Strickland J, et al: Arthrodesis for
post-traumatic arthritis of the wrist: reliability and function.
Paper presented at 42nd annual meeting of the American
Society for Surgery of the Hand, San Antonio, Tex, Sept 11,
1987.
Weiss AP, Hastings H II: Wrist arthrodesis for traumatic conditions: a study of plate and local bone graft application, J Hand
Surg 20A:50, 1995.
Wood M: Wrist arthrodesis using dorsal radial bone graft, J Hand
Surg 12A:208, 1987.
Wright CS, McMurtry RY: AO arthrodesis in the hand, J Hand
Surg 8A:932, 1983.
Yang RS, Liu TK: Arthrodesis of the nonrheumatoid wrist,
Taiwan Yi Xue Hui Za Zhi 88:258, 1989.
Zachary SV, Stern PJ: Complications following AO/ASIF wrist
arthrodesis, J Hand Surg 20A:339, 1995.

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Total Ankle Arthroplasty


http://bookmedico.blogspot.com
Chapter 5

Sue N. Ishikawa

General principles ................... 235


Patient selection .......................... 235
Preoperative deformity ............... 235
Operative technique ............... 236
Complications ..........................
Intraoperative ..............................
Malalignment ..................................
Fracture .........................................

237
237
237
238

Tendon injury ................................. 238


Postoperative ............................... 238
Syndesmotic nonunion ....................... 238
Wound problems .............................. 238
Infection ......................................... 238
Component instability and lysis .......... 238

Agility total ankle


arthroplasty ............................. 238
Scandinavian total ankle
replacement ............................. 239
Beuchel-Pappas total ankle
arthroplasty ............................. 239

Specic implants and


outcomes ............................... 238

Conclusion ................................ 240

Ankle arthrodesis has long been the gold standard for


the surgical treatment of ankle arthritis. As an alternative,
total ankle arthroplasty was rst introduced in the 1970s,
but enthusiasm for this procedure waned because of the
high rate of complications of these rst-generation designs.
Problems with the rst-generation arthroplasty included
wound breakdown, loosening of the implants, and deep
infection. Because these early designs required extensive
bony resection, salvage from these complications was
difcult.
There has been a renewed interest in total ankle arthroplasty as technique and prosthesis designs have improved.
The most commonly reported second-generation arthroplasty designs are cementless and include the two-component Agility (DePuy, Warsaw, Ind) prosthesis, which
requires a fusion of the syndesmosis, and the mobile bearing,
three-component designs, such as the Scandinavian Total
Ankle Replacement (STAR) prosthesis (Waldemar Link,
Hamburg, Germany) and the Buechel-Pappas (Endotec,
South Orange, NJ) arthroplasty. The Agility prosthesis is
approved by the U.S. Food and Drug Administration
(FDA), as is the STAR, and the Buechel-Pappas implant
currently is in clinical trials. More recent FDA-approved
devices are similar to the Agility and include the INBONE
Total Ankle Replacement (INBONE Technologies,
Boulder, Colo) (Fig. 5-1), the Salto Talaris Total Ankle
Prosthesis (Tornier, Stafford, Tex) (Fig. 5-2), and the
Eclipse Total Ankle Implant.

GENERAL PRINCIPLES
Patient Selection
The ideal candidates for total ankle arthroplasty are sedentary older individuals who are not obese and who have
minimal deformity, good range of motion of the ankle,
and a good soft-tissue envelope. In addition, patients who
have increased bone mineral density seem to be more
satised with the surgery. In contrast to in the hip or knee,
posttraumatic arthritis is more prevalent than osteoarthritis
in the ankle and tends to occur in younger patients who
place higher demands on the prosthesis and have soft tissues
that are compromised secondary to previous surgery or
injury. Total ankle arthroplasties should not be implanted
in patients with an active infection, patients with peripheral
vascular disease, or patients with Charcot arthropathy.
Relative contraindications include osteoporosis, osteonecrosis of the talus, severe malalignment or instability, and
previous infection.

Preoperative Deformity
The patient should be evaluated for deformity either proximal or distal to the ankle because this requires correction
before or at the time of implantation of the prosthesis. If
the deformity is not treated, it may lead to greater polyethylene wear and early failure of the implant. Osteotomies,

235

Ch005-A03329.indd 235

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236

Part III Arthroplasty

Tibial
stem

can lead to decreased range of motion after total ankle


arthroplasty.
A study by Saltzman et al. showed that the method of
training to learn the technique for performing total ankle
arthroplasty does not affect patient outcome. It seems to be
equally efcacious to learn the technique by visiting with
an expert, taking a course, or learning during fellowship.
There seems to be a signicant learning curve, however,
with better outcomes occurring after the rst 50 cases.

OPERATIVE TECHNIQUE
Talar
stem
Fig. 5-1

INBONE total ankle replacement device.

arthrodesis in the foot, or tendon transfers may be required.


Soft-tissue balancing may require lateral ligament reconstruction or deltoid release. Coronal plane deformity of
more than 10 degrees can be corrected intraoperatively by
the orientation of the bony cuts, lateral ligament reconstruction, or supercial deltoid release. If the deformity is
incongruent, however, these patients are 10 times more
likely to have progressive edge-loading. Soft-tissue contractures also should be treated. The most common problem
is gastrocnemius-soleus tightness, which, if not corrected,

Total Ankle Arthroplasty


TECHNIQUE 5-1 Clare, Sanders, and Walling
Place the patient supine with a bump beneath the ipsilateral
buttock and hip to internally rotate the limb. Prepare and drape
the limb, and place sterile bumps under the knee and ankle to
help level the lower leg and relax the soft tissues. The distal
bump can be moved out of the path of the saw when
performing bone cuts so that the soft tissue is relaxed. This
avoids injury to the tendons and neurovascular structures.
Exsanguinate the limb with an Esmarch bandage, and inate
the tourniquet. Some arthroplasty systems require the use of an
external xator. This should be applied before the tourniquet is
inated. Perform an Achilles tendon lengthening as necessary.
Make a linear incision overlying the interval between the
anterior tibial and common extensor tendons. Continue sharp
dissection through the underlying extensor retinaculum. Avoid
the sheath of the anterior tibial tendon, which could lead to
scarring and affect ankle motion. Also, avoid the anterior tibial
artery and deep peroneal nerve. The neurovascular bundle
generally courses laterally beneath the extensor hallucis longus
tendon at the proximal portion of the incision and migrates
medially with the extensor hallucis longus tendon at the distal
portion of the incision overlying the talar neck and head.
Continue the sharp dissection down to bone, and perform an
arthrotomy.
Elevate the ankle joint capsule, and develop subperiosteal aps
medially and laterally until the ankle joint is adequately exposed.
Maintain the integrity of the periosteal ap because this prevents
inadvertent injury to tendons or neurovascular structures.
Excise any osteophytes at the distal tibia or talar neck with a
rongeur or small osteotome so as not to impinge against the
cutting guides.

Fig. 5-2

Ch005-A03329.indd 236

Salto Talaris total ankle replacement device.

For arthroplasty systems that require a syndesmosis


arthrodesis, carry the subperiosteal dissection laterally until the
lateral margin of the bula is exposed. Alternatively, a separate
small incision may be made anterolaterally over the syndesmosis.
Incise sharply the anterior inferior tibiobular ligament and
syndesmotic ligament over the distal syndesmosis. A lamina

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237

Chapter 5 Total Ankle Arthroplasty

spreader may be placed just proximal to the syndesmosis


articulation to facilitate exposure.

Select and place the nal components.

Dbride the articular surfaces with a hand-held burr or

the hinge to facilitate placement of the prosthesis. Impact the


tibial and talar components into place; ensure that the anterior
edge of the tibial component is impacted ush with the anterior
cortex of the distal tibia.

rongeur until sufciently prepared.

Size the cutting guide, and place it over the distal tibia and
talus. Use uoroscopy to ne-tune the position.
For systems requiring use of an external xator, apply the
xator frame, and lock the ankle in neutral. Prophylactic screws
may be placed medially or laterally to protect the medial and
lateral malleoli before making the tibial cut. A bular plate and
screws also may be used.

Align the cutting guide in neutral, and verify that it is


symmetrical in the coronal plane. This ensures that equal
amounts of bone are excised medially and laterally, while
preserving sufcient remaining bone stock in the malleoli to
support the prosthesis. The cutting guide also must be balanced
in the vertical plane to preserve the subchondral bone of the
distal tibia and to avoid violating the subtalar joint posteriorly.

For arthroplasty systems requiring an external xator, unlock

Assess the placement of the components under direct vision


and under uoroscopy.
For arthroplasty systems requiring arthrodesis of the distal
syndesmosis, place bone autograft from the excised portions of
the distal tibia and talus in the previously prepared syndesmotic
bed. Place additional allograft material as needed. Place
syndesmosis screws in lag fashion just proximal to the autograft.
Osteotomize the bula proximal to the screws to decompress the
arthrodesis. Alternatively, the screws may be placed through a
supplemental buttress plate on the bula.
Irrigate the wound, and place a deep drain to decompress the
soft-tissue aps of any hematoma or drainage.

If the patients anatomy is between sizes of prostheses, use

Remove the external xator if necessary, and close the wound

the smaller component to maximize motion and to avoid


overstufng the joint. Verify alignment under direct vision and
uoroscopically.

in layers. Close the retinaculum and ankle capsule to afford deep


closure over the prosthetic components and to prevent
bowstringing of the anterior tibial and extensor tendons.
Approximate the subcutaneous layer with absorbable sutures to
decrease tension on the skin sutures. Close the epidermal layer
with nonabsorbable, monolament suture.

Secure the cutting guide to the distal tibia. Alternatively, the


guide may be secured to the limb proximally. A small lap sponge
or towel can be placed beneath the proximal arm of the guide.
Conrm alignment of the cutting guide before making the bony
cuts. Extreme care must be taken while completing the cuts to
prevent injury to the peroneal, exor hallucis longus, and
posterior tibial tendons.
When the cuts are made, free the excess bone with
osteotomes and remove. Excise the remainder of the posterior
ankle capsule, while preserving the tendon sheaths to the
aforementioned tendons.
For two-piece arthroplasty systems, make supplemental cuts
with the reciprocating blade in the medial and lateral gutters off
of the residual talus to facilitate sagittal plane motion and to
prevent bony impingement against the tibial prosthesis.
Irrigate the joint thoroughly to facilitate removal of any bony
or soft-tissue debris before placement of the trial components.
Place the trial components, and assess the joint under direct
vision and using uoroscopy.
Take the limb through a range of motion; generally, a motion
arc of at least 30 degrees should be obtained intraoperatively,
including 10 degrees of dorsiexion. Evaluate the ankle for
proper ligament balance and adequate tension. Insufcient ankle
motion may be caused by overstufng the joint, and a smaller
talar component should be used, or a polyethylene tibial spacer
may be benecial in improving ankle motion. An Achilles tendon
contracture also may inhibit ankle motion if an Achilles
lengthening procedure was not done previously.

Ch005-A03329.indd 237

Apply sterile dressings, a bulky Jones dressing, and plaster


splint, holding the ankle in neutral.
AFTERTREATMENT

Postoperatively, the involved limb is


immobilized in a well-padded splint until the incisions
have healed adequately. A removable controlled ankle
motion (CAM) walker boot may be substituted to allow
initiation of early range-of-motion activities. Patients are
kept nonweight bearing, however, for approximately 8 to
10 weeks until sufcient early bone ingrowth has occurred
at the prosthetic-bone interface, and the distal syndesmosis
arthrodesis has adequately solidied as necessary. Aggressive
ankle motion is continued. Ideally, ankle range of motion
should be adequately restored during this interval to allow
a near-normal heel-to-toe gait. Weight bearing is advanced
initially in the CAM boot, which supports and stabilizes
the ankle and limits shear and rotational forces on the
prosthesis. The patient is gradually weaned from the CAM
boot over the ensuing weeks as activity levels are gradually
increased.

COMPLICATIONS
Intraoperative
Malalignment
If the joint line is raised by an excessive tibial cut, the tibial
component rests on softer metaphyseal bone, which may

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238

Part III Arthroplasty

lead to subsidence and gutter impingement. Lowering the


joint line leads to tightness of the gastrocnemius-soleus
complex and subsequent stiffness of the joint.
Coronal plane deformity should be less than 4 degrees;
otherwise, pain and edge-loading may occur. Varus malpositioning can lead to medial impingement, stiffness,
excessive lateral foot pressure, and edge wear. Valgus
malalignment may result in lateral impingement, arch pain
from overstretching, and edge wear.
Medial translation of the tibial component causes a
higher risk of medial malleolar fracture. Lateral translation
places excessive tension on the deltoid, which tips the talus
into varus.
Fracture
Medial and lateral malleolar fractures can occur intraoperatively from overzealous cuts or malpositioning of the
cutting jig. They should be xed if recognized intraoperatively, or malposition of the component or poor implant
xation and subsequent loosening may occur.
Tendon Injury
The posterior tibial tendon and the peroneal tendons are
at risk if saw blades penetrate too far posteriorly.

Component Instability and Lysis


Migration of 5 mm or more or angular change of 5 degrees
or more may lead to a poor clinical outcome. The talar
component subsides more often than the tibial component,
and progressive lysis or circumferential lucency may lead
to a poor outcome.

SPECIFIC IMPLANTS
AND OUTCOMES
Agility Total Ankle Arthroplasty
The Agility arthroplasty is a xed bearing, two-component
design with the polyethylene locked into the tibial component (Fig. 5-3). Partial conformity between the tibial and
talar components may decrease stress transfer to the boneprosthesis interface, but may increase wear. Syndesmosis
fusion is required to use the bula for more support of the
tibial component. This implant requires a larger talar resection than other designs, and a distractor is needed to make
relatively aggressive bone cuts.
Knecht et al. reported their intermediate results at an
average follow-up of 9 years in 132 patients who had

Postoperative
Syndesmotic Nonunion
Nonunion of the syndesmosis is a complication unique to
the Agility prosthesis because this is the only prosthesis that
requires a syndesmosis fusion to provide support to the
tibial component. Nonunion may lead to loosening of the
tibial component, with angular change or subsidence. With
the use of one screw, there is a longer time to union as
opposed to the use of two screws.

Wound Problems
Wound healing problems are common because there is a
thin soft-tissue envelope around the ankle as opposed to
the hip and knee. In addition, the anterior incision, which
is used most often for this procedure, is in the middle of
an angiosome, which makes it riskier than one that is
between angiosomes. These complications can be minimized with proper soft-tissue handling technique, including making the incision long enough to minimize excessive
retraction and avoiding overdistraction with the external
xator.
Infection
Infection should be treated as with other joint arthroplasties. Deep infection should be treated with aggressive
dbridement, an antibiotic cement spacer, and delayed
fusion.

Ch005-A03329.indd 238

B
Fig. 5-3

A and B, Agility 2 total ankle replacement

device.

7/25/2007 11:45:24 AM

239

Chapter 5 Total Ankle Arthroplasty

implantation of the Agility prosthesis. Of these patients,


92% were satised with the outcome of the surgery, and
97% would recommend the surgery to a friend. There was
an 11% major revision rate, and 32 of 132 (27%) required
other secondary procedures. Seventy-six percent of ankles
had periprosthetic lucencies seen on radiographs.
In another study of 306 ankles at a mean follow-up of
33 months, Spirt et al. had a 28% reoperation rate (most
commonly for dbridement), 10% revision fusion rate, and
5-year implant survival rate of 80%. Older patients in this
series were at less risk for reoperation and failure of the
prosthesis.
Kopp et al., in their study of 43 ankles with an average
follow-up of 44.5 months, had a patient satisfaction rate of
97.5%. Of their patients, 85% had radiographic lucencies,
2% required revision surgery, and 23% required a second
operation. There were three medial and one lateral malleolar fractures that were xed intraoperatively. Three syndesmosis fusions went on to nonunion. A decrease in
complications was noted as experience with the procedure
increased.

Scandinavian Total Ankle Replacement


The other commonly used implant is the STAR, which is
a mobile bearing, three-component design (Fig. 5-4). The
mobile polyethylene component allows for less constraint

Beuchel-Pappas Total Ankle Arthroplasty

B
Fig. 5-4

device.

Ch005-A03329.indd 239

at the interface between it and the tibial component, which


reduces stress transfer to the bone-prosthesis interface, but
can allow more backside wear and less anterior-to-posterior
stability. There is more conformity between the polyethylene component and the talar component, which also is
thought to reduce wear. Implantation of this prosthesis
requires less aggressive talar cuts than the Agility implant.
It was originally a cemented prosthesis, but has been redesigned to be implanted without cement.
Kofoed et al., in an early report on the cemented STAR
prosthesis in 52 patients, compared 25 patients with osteoarthritis as the primary diagnosis with 27 patients with
rheumatoid arthritis. Six of 25 (24%) patients with osteoarthritis needed revision or arthrodesis compared with ve
of 27 (19%) with rheumatoid arthritis. There was a survivorship of 72.7% for osteoarthritis and 75.5% for rheumatoid arthritis at 14 years.
In another report on 100 patients with cemented and
uncemented prostheses at an average follow-up of 6 years,
Kofoed et al. compared one group (group A) of 30 patients
younger than 50 years with another group of 70 patients
older than 50 years (group B). In group A, there was one
revision and there were three fusions (13%); in group B
there were four revisions and four fusions (11%). There was
no difference in the subgroup of patients with posttraumatic arthritis when comparing young and old patients.
In another study on the uncemented STAR prosthesis
in 200 patients112 with rheumatoid arthritis, 56 with
osteoarthritis, and 25 with posttraumatic arthritiswith a
mean 46-month follow-up, Wood et al. had a 7% revision
or fusion rate, and another 4% had secondary surgeries.
There was an 87.9% 8-year implant survivorship rate.
There were nine intraoperative malleolar fractures (eight
medial, one lateral), and 10 fractures occurred postoperatively, all in the medial malleolus. There were 14 patients
with loosening, and nine with edge-loading. Delayed
wound healing was more common in patients with rheumatoid arthritis, and pain and stiffness were more common
in patients with posttraumatic arthritis.
Anderson et al. implanted the uncemented STAR prosthesis in 51 patients and reported their 3- to 8-year followup. There was a 24% revision rate and a 5-year implant
survival rate of 70%. Of the 51 patients, 31 were satised
with the outcome of the surgery, two were somewhat satised, and six were dissatised. Preoperative and postoperative range of motion did not differ. The outcomes did not
seem to be different when comparing patients with posttraumatic arthritis, osteoarthritis, and rheumatoid arthritis
because the postoperative scores were not signicantly different in these patient groups.

A and B, Scandinavian total ankle replacement

The Beuchel-Pappas arthroplasty is a mobile bearing,


three-component design, which makes it minimally con-

7/25/2007 11:45:24 AM

240

Part III Arthroplasty

A
Fig. 5-5

A and B, Buechel-Pappas total ankle replacement

device.

strained and fully conforming as in the STAR (Fig. 5-5).


The talar component does not require resurfacing of the
medial and lateral facets as in the STAR, preserving more
bone stock, but providing less surface area for ingrowth.
The tibial component has a stem that must be implanted
through an anterior cortical window, but may provide
more support for the prosthesis.
Beuchel et al. reported 50 patients33 with posttraumatic arthritis, eight with osteoarthritis, seven with rheumatoid arthritis, and two with talar osteonecrosiswith a
mean follow-up of 5 years. They had 88% good or excellent, 6% fair, and 6% poor results. Two of 50 (4%) patients
required revision surgery; there was a 93.5% survivorship
rate at 10 years. Three medial malleolar fractures occurred
in the postoperative period.

CONCLUSION
Overall, improvement in technique and implant design has
led to better outcomes compared with rst-generation total
ankle arthroplasty. Results do not compare favorably with
total hip and total knee arthroplasty, however, and longterm outcomes are yet to be determined.

References

Attinger CE, Cooper P, Bloom P, et al: The safest surgical incisions and amputations applying the angiosome principles and
using the Doppler to assess the arterial-arterial connections of
the foot and ankle, Foot Ankle Clin N Am 6:745, 2001.
Buechel FF, Buechel FF, Pappas MJ: Eighteen-year evaluation of
cementless meniscal bearing total ankle replacements, Instr
Course Lect 51:143, 2002.
Buechel FF, Buechel FF, Pappas MJ: Ten-year evaluation of
cementless Buechel-Pappas meniscal bearing total ankle
replacement, Foot Ankle Int 24:462, 2003.
Clare MP, Sanders RW, Walling AK: Total ankle arthroplasty. In
Orthopaedic knowledge online, AAOS, 2003. Available at http//
www.5.aaos.org/oko/foot_ankle/total_ankle_arthroplasty/
surgery.
Conti SF, Wong YS: Complications of total ankle replacement,
Clin Orthop Relat Res 391:105, 2001.
Easely ME, Vertullo CJ, Urban WC, et al: Total ankle arthroplasty, J Am Acad Orthop Surg 10:157, 2002.
Gill LH: Principles of joint arthroplasty as applied to the ankle,
Instr Course Lect 51:117, 2002.
Gill LH: Challenges in total ankle arthroplasty, Foot Ankle Int
25:195, 2004.
Haskell A, Mann RA: Ankle arthroplasty with preoperative
coronal plane deformity: short-term results, Clin Orthop Relat
Res 424:98, 2004.
Knecht SI, Estin M, Callaghan JJ: The Agility total ankle arthroplasty: seven to sixteen-year follow-up, J Bone Joint Surg
86A:1161, 2004.
Kofoed H: Cylindrical cemented ankle arthroplasty: a prospective
series with long-term follow-up, Foot Ankle Int 16:474, 1995.
Kofoed H, Lundberg-Jensen A: Ankle arthroplasty in patients
younger and older than 50 years: a prospective series with
long-term follow-up, Foot Ankle Int 20:501, 1999.
Kofoed H, Sorensen TS: Ankle arthroplasty for rheumatoid
arthritis and osteoarthritis: prospective long-term study of
cemented replacements, J Bone Joint Surg 80B:328, 1998.
Kopp FJ, Patel MM, Deland JT, et al: Total ankle arthroplasty
with the Agility prosthesis: clinical and radiographic evaluation, Foot Ankle Int 27:97, 2006.
McGarvey WC, Clanton TO, Lunz D: Malleolar fracture after
total ankle arthroplasty: a comparison of two designs, Clin
Orthop Relat Res 424:104, 2004.
Myerson MS, Miller SD: Salvage after complications of total
ankle arthroplasty, Foot Ankle Clin N Am 7:191, 2002.
Myerson MS, Mroczek K: Perioperative complications of total
ankle arthroplasty, Foot Ankle Int 24:17, 2003.
Pyevich MT, Saltzman CL, Callaghan JJ, et al: Total ankle
arthroplasty: a unique design, two to twelve-year follow-up,
J Bone Joint Surg 80A:1410, 1998.
Saltzman CL, Amendola A, Anderson R, et al: Surgeon training
and complications in total ankle arthroplasty, Foot Ankle Int
24:514, 2003.
Spirt AA, Assal M, Hansen ST: Complications and failure after
total ankle arthroplasty, J Bone Joint Surg 86A:1172, 2004.
Wood PLR: Experience with the STAR ankle arthroplasty at
Wrightington Hospital, UK, Foot Ankle Clin N Am 7:755,
2002.
Wood PLR, Deakin S: Total ankle replacement: the results in
200 ankles, J Bone Joint Surg 85B:334, 2003.
Zerahn B, Kofoed H: Bone mineral density, gait analysis, and
patient satisfaction, before and after ankle arthroplasty, Foot
Ankle Int 25:208, 2004.

Anderson T, Montgomery F, Carlsson A: Uncemented STAR


total ankle prostheses, J Bone Joint Surg 84A:1321, 2003.

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Arthroplasty of the Knee

John R. Crockarell, Jr James L. Guyton

Modern prosthesis evolution


and design ............................
Varus-valgus constrained
prostheses ................................
Mobile bearing prostheses ..........
Unicompartmental prostheses .....
Hinged implants .........................
Prosthesis systems .......................

241
243
244
244
245
245

Biomechanics of knee
arthroplasty ........................... 246
Kinematics .................................. 246
Role of the posterior cruciate ligament in
total knee arthroplasty ................... 247
Axial and rotational alignment of the
knee .......................................... 249
Patellofemoral joint ........................... 250
Polyethylene issues ...................... 253
Component xation ................... 255

Indications and
contraindications for total
knee arthroplasty .................
Tricompartmental knee
replacement .............................
Unicondylar knee
arthroplasty .............................
Indications for patellar
resurfacing ...............................

256
256

Indications for simultaneous


bilateral total knee
arthroplasty ............................. 258
Results of primary total knee
arthroplasty ........................... 258
Functional and radiographic
outcome measures ................... 258
Prosthesis survival ...................... 259
Preoperative evaluation ......... 261
Anesthetic options ...................... 261
Surgical technique for primary
tricompartmental knee
replacement .......................... 262
Intramedullary and extramedullary
alignment instrumentation ............... 267
Computer-assisted alignment
technique .................................... 267
Ligamentous balancing ............... 268

Management of bone
deciency ................................
Patellofemoral tracking ...............
Wound closure ...........................
Postoperative management .........

272
273
276
278

Chapter 6

Previous high tibial


osteotomy ................................
Previous patellectomy .................
Neuropathic arthropathy ............
Other medical conditions ...........

278
279
280
280

Complications of total knee


arthroplasty ...........................
Thromboembolism .....................
Infection .....................................
Patellofemoral complications ......
Neurovascular complications ......
Periprosthetic fractures ...............

281
281
282
286
289
290

Revision total knee


arthroplasty ...........................
Aseptic failure of primary total
knee arthroplasty ....................
Surgical exposures for revision
arthroplasty .............................
Component removal ...................
Reconstruction principles ...........
Results of revision knee
arthroplasty .............................

291
291
294
296
296
299

256
257

Surgical problems relative to


specic disorders ................. 278

MODERN PROSTHESIS EVOLUTION


AND DESIGN
Although many total knee designs predate the total condylar prosthesis designed by Insall and others, its introduction in 1973 marked the beginning of the modern era of
total knee arthroplasty (TKA) (Fig. 6-1). This prosthesis
design allowed mechanical considerations to outweigh the
desire to reproduce anatomically the kinematics of normal
knee motion. Inuenced largely by the previous ICLH
(Imperial College/London Hospital) design, both cruciate
ligaments were sacriced, with sagittal plane stability main-

tained by the articular surface geometry. The original


cemented total condylar prosthesis dramatically reset the
standard for survivorship of total knee replacements;
Ranawat et al. reported a prosthetic survivorship of 94%
at 15-year follow-up.
The design of the total condylar prosthesis included a
chrome cobalt femoral component with a symmetrical
anterior ange for patellar articulation. The symmetrical
femoral condyles had a decreasing sagittal radius of curvature posteriorly and were individually convex in the coronal
plane. The double-dished articular surface of the tibial
polyethylene component was perfectly congruent with the

241

Ch006-A03329.indd 241

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242

Part III Arthroplasty

Fig. 6-1 Total condylar prosthesis introduced by Insall in


1973. (From Insall JN, Lachiewicz PF, Burstein AH: The posterior stabilized condylar prosthesis: a modication of the total
condylar design: two to four-year clinical experience, J Bone Joint
Surg 64A:1317, 1982).

femoral component in extension and congruent in the


coronal plane in exion. Translation and dislocation of the
components were resisted by the anterior and posterior lips
of the tibial component and the median eminence. The
tibial component had a metaphyseal stem to resist tilting of
the prosthesis during asymmetrical loading. The tibial
component originally was all-polyethylene, but metal
backing was added later to allow more uniform stress transfer to the underlying cancellous metaphyseal bone and to
prevent polyethylene deformation. The patella was resurfaced with a dome-shaped, all-polyethylene patellar com-

ponent with a central xation lug. Many of these design


characteristics are retained in current designs.
Concurrent with the development of the cruciatesacricing total condylar prosthesis, the duopatellar prosthesis was developed with the sagittal plane contour of the
femoral component being anatomically shaped. This prosthesis included retention of the posterior cruciate ligament
(PCL). Originally, the medial and lateral tibial plateau
components were separate, but this was soon revised to a
one-piece tibial component with a cutout for PCL retention. The patellar component of the duopatellar prosthesis
was an all-polyethylene dome similar to that used in the
total condylar knee. The duopatellar prosthesis evolved into
the kinematic prosthesis, which was widely used in the
1980s (Fig. 6-2).
Two early criticisms of the total condylar prosthesis were
its tendency to subluxate posteriorly in exion if the exion
gap was not balanced perfectly with the extension gap and
a smaller range of exion compared with prosthetic designs
that allowed femoral rollback to occur. By not rolling
back, the posterior femoral metaphysis in a total condylar
knee impinged against the tibial articular surface at approximately 95 degrees of exion (Fig. 6-3). The early clinical
reviews of the total condylar prosthesis documented average
exion of only 90 to 100 degrees. To correct these problems, the Insall-Burstein posterior cruciatesubstituting or
posterior-stabilized design was developed in 1978 by adding
a central cam mechanism to the articular surface geometry
of the total condylar prosthesis (Fig. 6-4). The cam on the
femoral component engaged a central post on the tibial
articular surface at approximately 70 degrees of exion and
caused the contact point of the femoral-tibial articulation
to be posteriorly displaced, effecting femoral rollback and
allowing further exion.
Most current total knee designs are derivatives of the
Insall-Burstein and kinematic designs. During the late

Fig. 6-2 Kinematic condylar prosthesis. (From Rand


JA: Posterior cruciateretaining total knee arthroplasty. In
Morrey BF, ed: Reconstructive surgery of the joints, 2nd ed,
New York, 1996, Churchill Livingstone. By permission of
Mayo Foundation.)

Ch006-A03329.indd 242

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Chapter 6 Arthroplasty of the Knee

243

1980s and 1990s, patellofemoral complications became the


primary cause for reoperation in TKA. Consequently,
improved reconstruction of the patellofemoral joint has
received attention in more recent designs. Newer designs
incorporate greater areas of patellofemoral contact through
a larger range of motion and asymmetrical anterior anges
designed to resist patellar subluxation.
Some total knee systems have incorporated a deep-dish
design as one of their available modular tibial polyethylene
options. This design is similar to the original total condylar
design that uses sagittal plane concavity or dishing alone
to control anteroposterior stability (Fig. 6-5). In comparing
deep-dish components with posterior-stabilized devices
using the same femoral components, Laskin et al. found no
difference at follow-up in range of motion, ability to climb
or descend stairs, or pain scores. They believed this design
incorporated many of the previously mentioned advantages
of cruciate sacrice without the obligatory bone sacrice
in the intercondylar region of the femur, which may predispose to fracture. They claimed that with proper exionextension gap balancing, posterior impingement in exion
was avoided, yielding exion similar to the posteriorstabilized design.

Varus-Valgus Constrained Prostheses


Total condylar design is limited in exion by posterior impingement of femur on tibial polyethylene component. With posterior cruciate ligament retention and
substitution, femoral rollback allows greater exion. (From
Krackow KA: The technique of total knee arthroplasty, St Louis,
1990, Mosby.)
Fig. 6-3

Fig. 6-4

Ch006-A03329.indd 243

Insall-Burstein II posterior-stabilized knee.

The original constrained condylar knee (CCK) was developed by Insall and others from the posterior-substituting
design by enlarging the central post of the tibial polyethylene insert, constraining it against the medial and lateral
walls of a deepened central box of the femoral component
(Fig. 6-6). Varus-valgus stability is controlled by this
mechanism with a small amount of varus-valgus toggle
allowed. This type of prosthesis otherwise functions as a

Fig. 6-5 Deep-dish component. (From Laskin RS, Maruyama


Y, Villaneuva M, et al: Deep-dish congruent tibial component
use in total knee arthroplasty: a randomized prospective study,
Clin Orthop Relat Res 380:36, 2000.)

7/25/2007 11:46:42 AM

244

Fig. 6-6

Part III Arthroplasty

Insall-Burstein II constrained condylar knee.

posterior-stabilized design and is used in patients with


instability that might otherwise require a hinged prosthesis.
It cannot be used for recurvatum deformity because it does
not control hyperextension. Originally designed with
cemented intramedullary stems on femoral and tibial components, the design evolved to include modular press-t or
cemented intramedullary stems on the tibial and femoral
components.
The CCK design has been used extensively for revision
arthroplasty when instability is present and for difcult
primary arthroplasties in patients with extreme valgus
deformity and medial collateral ligament insufciency.
Easley et al. reported no loosening at 8 years in a group of
28 CCK knees implanted for severe valgus deformities in
an older patient group (average age 73). The added constraint of the CCK design raises the concern, however, of
whether it would incur increased rates of loosening, particularly when used in younger patients. Rosenberg, Verner,
and Galante reported progressive bone cement radiolucencies in 16% of patients at an average of 44 months after
arthroplasty with the total condylar prosthesis III, the precursor of the CCK. Donaldson et al. reported no failures
at 4-year follow-up in 17 primary arthroplasties with the
total condylar prosthesis III in knees with severe valgus
deformities; ve failures occurred in 14 revision arthroplasties. Most total knee systems include a variation of a varusvalgus constrained design.

Mobile Bearing Prostheses


The meniscal-bearing version of the low contact stress
(LCS) prosthesis developed by Buechel and others incorporated many of the features of the earlier Oxford knee.

Ch006-A03329.indd 244

Individual polyethylene menisci articulate with the femoral


component above and with a polished tibial baseplate
below. The LCS design has additional dovetailed arcuate
grooves on the tibial baseplate that control the anteroposterior course of the menisci. The femoral component has
a decreasing radius of curvature posteriorly. This modication of the Oxford design decreases the posterior excursion
of the menisci in exion, helping to decrease the incidence
of posterior extrusion of the menisci. Jordan, Olivo, and
Voorhorst reported a 94% 8-year survival rate for the
cementless version of this design.
The LCS total knee system also includes a rotating
platform design with congruent tibiofemoral geometry in
extension similar to other current deep-dish designs;
however, the tibial polyethylene is additionally free to
rotate within the stem of the tibial baseplate. This design
has had rare rotational dislocations of the tibial inserts
because of inadequate exion-extension gap balancing, but
it has exhibited excellent longevity. Callaghan et al.
reported a 100% prosthesis survival rate in 82 patients at a
minimum of 9-year follow-up of the cemented rotating
platform LCS design. In a later follow-up study, Callaghan
et al. reported the status of 53 knees in 37 of these patients
who were still living at a minimal follow-up of 15 years.
None of the knees had required revision because of loosening, osteolysis, or wear; three knees had required reoperationtwo for periprosthetic fractures and one for
infectionbut none of the components were revised as
part of the reoperations. Buechel, one of the developers of
the LCS design, reported a 98% 20-year survivorship with
this design and a similar survivorship at 18 years with the
cementless rotating platform design.
Potential advantages of mobile bearing knees include
lower contact stresses at the articulating surfaces, rotational
motion of the tibial polyethylene during gait, and selfalignment of the tibial polyethylene compensating for small
rotational malalignment of the tibial baseplate during
implantation. Whether mobile bearing designs will outperform xed bearing designs is yet to be determined. Most
prosthesis companies now include mobile bearing designs.

Unicompartmental Prostheses
Although controversial, many surgeons advocate the use of
unicompartmental knee arthroplasty (UKA) for arthritis
limited to only one knee compartment (Fig. 6-7). These
prostheses replace the articular surface of either the medial
or the lateral femoral condyle and the adjacent tibial plateau
surface. The current trend toward minimally invasive
surgery has rekindled enthusiasm for these devices despite
the fact that most studies, with some notable exceptions,
have shown a slightly worse survivorship for UKA compared with TKA.
Marmor introduced a unicompartmental replacement in
the early 1970s, obtaining better results with replacement

7/25/2007 11:46:44 AM

Chapter 6 Arthroplasty of the Knee

245

Hinged Implants

Fig. 6-7 Omnit (Stryker, Kalamazoo, Mich) unicompartmental knee system.

The Kinematic Rotating Hinge (Howmedica, Rutherford,


NJ) (Fig. 6-8) has been a widely used linked, hinged knee
replacement. Two polyethylene and cobalt chrome bearings
allow exion-extension and axial rotation. Rand, Chao,
and Stauffer reported the Mayo Clinic results with the
Kinematic Rotating Hinge as being no better than the
earlier GUEPAR prosthesis with respect to infection, loosening, and patellar complications. A more recent study of
hinged prostheses by Jones, Barrack, and Skedros found a
much lower complication rate at 4-year follow-up of the
S-ROM hinged prosthesis ( Joint Medical Products/Johnson
& Johnson, Stamford, Conn). This type of prosthesis is
used in patients with severe ligamentous insufciency,
severe exion or extension gap mismatch, recurvatum
deformity, and limb salvage procedures.

Prosthesis Systems
of the lateral compartment than of the medial compartment. The Marmor prosthesis was anatomically shaped
with a at, all-polyethylene tibial component. Squire et al.
observed 87.5% 15-year survivorship using this prosthesis.
Subsequent unicompartmental prostheses with metalbacked tibial components and thin polyethylene occasionally exhibited rapid polyethylene wear.
Meniscal-bearing unicompartmental knee replacements
allow translational motion at the polyethylene tibial baseplate interface similar to meniscal-bearing TKA and are
enthusiastically supported by some authors. Goodfellow,
OConnor, and Murray reported a 96% 10-year survivorship of the unicompartmental Oxford meniscal knee
arthroplasty. In the Swedish National Registry, the Oxford
unicompartmental knee fared worse, having a 7% revision
rate by 6 years.
Sparing of the cruciate ligaments, the opposite tibiofemoral compartment, and the patellofemoral joint in UKA
is purported to result in more normal knee kinematics
and to allow easy revision to a tricompartmental prosthesis
at a later time. A more normal knee possibly can be
obtained with UKA with quicker rehabilitation time and
greater range of motion than with TKA. The second
purported advantagebone stock preservationis more
controversial. Revision of UKA to tricompartmental prostheses, requiring special components, bone grafting, or
cement with screw augmentation to ll osseous defects,
was necessary in 76% of patients reported by Padgett,
Stern, and Insall and in 45% reported by Barrett and Scott.
McAuley, Engh, and Ammeen reported a 26% use of local
autograft, whereas 21% required wedge augmentation.
They commented that the UKA revisions to TKA were
simpler than typical revision TKA. An emphasis on more
limited tibial resection with many newer designs may lessen
the incidence of signicant bony defects at the time of
revision.

Ch006-A03329.indd 245

Different types of prostheses are necessary for varying


amounts of arthritic involvement, deformity, laxity, and
bone loss. Prostheses used range from unicompartmental
designs for single-compartment disease with minimal
deformity to hinged prostheses for salvage procedures.
Many surgeons advocate the use of PCL-retaining prostheses for mild deformity and PCL-substituting designs for
more severe deformity. Knee prosthesis manufacturers have
developed prosthesis families that offer either PCL retention or PCL substitution through modular tibial polyethylene inserts and PCL-substituting and PCL-retaining
femoral components that require similar bone cuts. These
prosthesis families typically use shared operative instrumentation and allow an intraoperative change from PCL
retention to PCL substitution or even a constrained condylar design. If balancing of the PCL is difcult, the
arthroplasty can be converted to a PCL-substituting design
with relative ease. Many prosthesis designs also include a
tibial polyethylene component with signicant dishing in

Fig. 6-8 Kinematic II Rotating Hinge (Howmedica) total


knee implant.

7/25/2007 11:46:44 AM

246

Part III Arthroplasty

the sagittal plane for optional use instead of the posteriorstabilized design when the PCL is incompetent. Modular
stems and metal augments and constrained condylar components are typically available.
Many other factors are important in prosthesis design
and selection, including prosthesis xation, the handling of
the patellofemoral articulation, modularity, and polyethylene issues. These are discussed in subsequent sections of
this chapter. It is the surgeons responsibility to understand
the indications, contraindications, expected functional
outcome, and longevity for each prosthesis type and for
specic prostheses. Long-term follow-up studies will continue to improve our understanding of appropriate indications for the variety of available knee prostheses.

Instant centers

20
50
120

BIOMECHANICS OF KNEE
ARTHROPLASTY

80

50
120

Kinematics
Knee motion during normal gait has been studied by many
investigators, who have found it to be much more complex
than simple exion and extension. Knee motion during
gait occurs in exion and extension, abduction and adduction, and rotation around the long axis of the limb (Fig.
6-9). Knee exion, which occurs around a varying transverse axis (Fig. 6-10), is a function of the articular geometry of the knee and the ligamentous restraints. Dennis et

Rotation
Extension

Abduction

Adduction

Flexion

Fig. 6-9 Motion in knee occurs in three separate planes


during course of normal gait cycle and is referred to as
triaxial motion.

Ch006-A03329.indd 246

Fig. 6-10 Transverse axis of exion and extension of knee


constantly changes and describes J-shaped curve around
femoral condyles.

al. described the exion axis as varying in a helical fashion


in a normal knee, with an average of 2 mm of posterior
translation of the medial femoral condyle on the tibia
during exion compared with 21 mm of translation of the
lateral femoral condyle. This observation was acquired by
dynamic uoroscopy coupled with three-dimensional CT
scans of the studied knees. The axis became more variable
after sectioning of the anterior cruciate ligament, with an
average 5 mm of medial condylar translation and 17 mm of
lateral condylar posterior translation in exion. This pattern
of medially based pivoting of the knee explains the observed
external rotation of the tibia on the femur during extension, known as the screw-home mechanism, and internal
rotation of the tibia during knee exion. The inability of
many early knee prosthesis designs to accommodate these
complex knee motions and their attendant stresses was an
unforeseen shortcoming. Many current prosthesis designs
attempt to reproduce normal knee kinematics closely,
whereas others settle for an approximation of normal
motion, placing other concerns, such as polyethylene
contact stresses, ahead of accurate reproduction of knee
kinematics.
The use of gait laboratories to study normal subjects and
patients before and after knee arthroplasty has become an
important tool in prosthesis design and later evaluation
(Fig. 6-11). In kinematic studies of the knee during selected
activities of daily living, Kettlekamp found that normal gait
required 67 degrees of exion during the swing phase, 83
degrees for stair climbing, 90 degrees for descending stairs,

7/25/2007 11:46:44 AM

Chapter 6 Arthroplasty of the Knee

Flexion

40
0

Extension

40

Adduction

10
0

Abduction

10

Internal rotation

10

External rotation

10

HO

HS

FF

TO

Fig. 6-11 Triaxial motion of normal knee during walking,


as measured by electrogoniometer. Flexion and extension are
about 70 degrees during swing phase and 20 degrees during
stance phase. About 10 degrees of abduction and adduction
and 10 to 15 degrees of internal and external rotation occur
during each gait cycle. FF, atfoot; HO, heel-off; HS, heelstrike; TO, toe-off. (From Kettelkamp DB: Gait characteristics
of the knee: normal, abnormal, and postreconstruction. In
American Academy of Orthopaedic Surgeons: Symposium on
reconstructive surgery of the knee, St Louis, 1978, Mosby.)

247

adequate exion. More recently, deep-dish designs with


increased sagittal plane conformity have been studied by
Scott and Thornhill (with PCL recession) and by Laskin
et al. and Hofmann et al. (with PCL sacrice). The exion
with these more conforming devices is similar to that with
the PCL-retaining and PCL-substituting devices with
which they have been compared.
In PCL-substituting designs, posterior displacement in
exion is produced by the tibial post contacting the femoral
cam, with the resultant stress borne by the prosthetic construct and ultimately transferred to the bone-cement interface (Fig. 6-12). Originally, this situation led many authors
to suggest that PCL-substituting designs would have higher
failure rates than PCL-retaining devices because of loosening. The loosening rates of these two designs are similar
at 10-year follow-up, however, and, at least for the initial
10 to 15 years after surgery, this argument does not seem
to be valid.
Gait analysis by Andriacchi and Galante, Kelman et al.,
and others found that individuals with PCL-retaining prostheses have a more symmetrical gait, especially during stair
climbing, than do individuals with either PCL-sacricing
or PCL-substituting designs. They showed decreased knee
exion during stair climbing and a tendency to lean forward
in a quadriceps-sparing posture in patients with PCL-

and 93 degrees to rise from a chair. Gait laboratory analysis


has driven further the direction of prosthesis development,
as discussed subsequently.
Role of the Posterior Cruciate Ligament in Total
Knee Arthroplasty
Since the concurrent development of PCL-retaining and
PCL-substituting prostheses, the relative merits of each
design have been debated. Each design boasts multiple
series with comparable excellent 10- to 15-year results.
Studies of bilateral TKA with a PCL-retaining prosthesis
on one side and a PCL-substituting prosthesis on the other
side have failed to show signicant subjective performance
or patient satisfaction differences. A closer look at the differences in these designs illustrates, however, many of the
factors involved in successful arthroplasty.
PCL retention achieves an increased potential range of
motion by effective femoral rollback and a relatively at
tibial articular surface. PCL substitution achieves femoral
rollback by a tibial post and femoral cam mechanism.
Compared with the original total condylar design, both
designs attain greater exion (see Fig. 6-3). In multiple
studies comparing PCL-retaining and PCL-substituting
prostheses, the average exion attained at long-term followup has been similar. When the PCL is retained, it frequently needs to be partially released or recessed to allow

Ch006-A03329.indd 247

Fig. 6-12 One argument against posterior cruciate ligament


substitution is that added prosthetic constraint may ultimately
transfer more stress to prosthesis-bone interface. (Redrawn
from Krackow KA: The technique of total knee arthroplasty, St Louis,
1990, Mosby.)

7/25/2007 11:46:44 AM

248

Part III Arthroplasty

sacricing and PCL-substituting designs. They postulated


that these observations may indicate inadequate rollback of
these designs or possibly the loss of a proprioceptive role
of the PCL. These observations have been cited as reasons
to retain the PCL. Gait analysis by Wilson et al. contradicts
the conclusions of these earlier studies, however, after comparing PCL-substituting knees with normal controls. These
earlier observations are refuted further by in vivo studies
by Stiehl et al.; Victor, Banks, and Bellemans; and Dennis
et al., who used uoroscopy during single-stance deep knee
bends to show a paradoxical forward translation of the
femorotibial contact point during weight bearing exion
in some PCL-retaining knees; PCL-substituting knees
studied showed more uniform femoral rollback.
The patellofemoral joint functions with a larger extensor
lever arm when femoral rollback, as a function of PCL
retention or PCL substitution, moves the tibial tubercle
more anteriorly. The patellofemoral joint also is affected by
joint line elevation, the extent to which the new prosthetic
joint line is raised relative to the native joint line. PCLretaining designs do not tolerate much alteration in the
level of the preoperative joint line while balancing the
exion and extension gaps, whereas PCL-substituting
designs frequently balance with some mild elevation of the
joint line. The relationship of the patella to the joint line
is potentially altered more with PCL-substituting prostheses than with PCL-retaining designs. Figgie et al. suggested
that joint line elevation may alter patellofemoral mechanics
and result in postoperative pain and subluxation.
PCL-substituting femoral components have a cutout for
a cam mechanism that begins just below the trochlea of
the patellofemoral joint. Additional bone is removed from
the femur when PCL-substituting designs are used to
accommodate this box-and-cam mechanism. Additionally,
the degree of exion at which the patella contacts this
box varies among different posterior-stabilized designs.
The patella and hypertrophic synovium on the undersurface of the quadriceps tendon can bind in this mechanism.
This clinical entity, termed patellar clunk syndrome by Hozack
et al., is a potential complication of PCL-substituting
designs.
Many authors argue that the PCL is diseased with
various forms of arthritis and contracture and is difcult
to balance reproducibly. Although intraoperative tests of
PCL balance have been devised by advocates of PCL retention, such as Ritter and Scott, other investigators, including
Mahoney et al., have stated that it is difcult, even in a
laboratory setting, to reproduce near-normal PCL strain
and function in a PCL-retaining knee arthroplasty.
Mahoney et al. stated that to have near-normal strain,
the PCL needs to be balanced to an accuracy of approximately 1 mm. A PCL that is too tight in exion can limit
the extent of exion attained postoperatively and lead
to excessive femoral rollback, which multiple retrieval
studies have shown to accelerate posterior tibial polyethyl-

Ch006-A03329.indd 248

ene wear. Some authors have suggested that attaining reliable balance of the PCL requires experience, and that
surgeons who perform fewer than 20 TKAs a year should
use PCL-substituting prostheses. Late rupture of the PCL
also is thought to be a cause of late instability in PCLretaining designs.
Another argument in favor of PCL substitution is that
signicant deformity can be more reliably corrected with
its use. Scott and Volatile stated that extensive collateral
ligament release on the concave side of a xed knee deformity may not be effective without release of the contracted
PCL, which acts as a tether. Similarly, if the collateral ligament on the convex side of a deformity is signicantly
stretched or attenuated, opposite collateral ligament release
is effective only in achieving varus-valgus balance to the
extent that is allowed by the intact PCL. Laskin et al.
reported a series of patients with preoperative xed varus
or valgus deformities of 15 degrees or more associated with
exion contractures. Such knees treated with PCL retention had less postoperative exion, more severe residual
exion contractures, and less correction of the mechanical
axis than knees with PCL substitution. Faris et al. found
no correlation, however, between preoperative deformity
and postoperative outcome in a large series of knees treated
with PCL retention.
Polyethylene wear is affected by prosthesis design and
by its in vivo kinematics. The tibial articular surface of
PCL-retaining prostheses is typically less conforming to
the femoral component in the sagittal plane to allow
femoral rollback. This less conforming geometry in the
sagittal plane is responsible for higher tibial polyethylene
contact stresses in PCL-retaining prostheses (Fig. 6-13).
Several authors have suggested that these greater contact
stresses are responsible in part for accelerated polyethylene
wear. This wear can be compounded by an excessively
tight PCL that may increase the polyethylene contact stress
as it becomes tight in exion. In the extreme, a PCL that
is tight in exion can cause the femoral condyles to override the posterior edge of the tibial polyethylene, causing
extremely high polyethylene contact stresses. This mechanism of accelerated posterior wear has been proposed after
study of retrieved polyethylene specimens by various
authors, including Wasielewski et al., Wright et al., and
Rose et al. More recently, Dennis et al. expressed concern
that paradoxical anterior tibial translation in exion in a
poorly functioning PCL-retaining knee may lead to early
polyethylene wear. Conversely, the tibial post on many
PCL-substituting designs has been shown by Puloski et al.
and ORourke et al. to be a site of wear and occasional
breakage, particularly when the femoral component can
impinge on the post anteriorly in hyperextension. This
condition is accentuated when the femoral component is
implanted in a exed postion, when the tibial component
is implanted with a greater posterior slope, and when the
knee hyperextends.

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Chapter 6 Arthroplasty of the Knee

Tibial sagittal plane geometry

Flat

Concave

ing this line distally. The mechanical axis of the tibia runs
from the center of the tibial plateau to the center of the
tibial plafond, accounting for any bowing of the tibia. The
angle formed between these separate mechanical axes of
the femur and tibia determines the varus or valgus deviation from the neutral mechanical axis. By determining the
tibial mechanical axis using the center of the tibial plateau
and the femoral mechanical axis using the center of the
intercondylar notch, any medial or lateral subluxation
through the knee joint is disregarded. Insall argued that
rotation affects the mechanical axis of the femur apparent
on an anteroposterior radiograph, lessening the value of
these preoperative measurements.
In a normal knee, the tibial articular surface is in
approximately 3 degrees of varus with respect to the

Mechanical
axis

Femoral
shaft axis
6

Vertical
axis

Fig. 6-13 Posterior cruciate ligamentretaining prostheses


have atter sagittal plane geometry, with resultant higher
tibial polyethylene contact stress. (Redrawn from Insall JN:
Historical development, classication, and characteristics of knee
prostheses. In Insall JN, ed: Surgery of the knee, 2nd ed, New
York, 1993, Churchill Livingstone.)

Axial and Rotational Alignment of the Knee


Numerous studies have shown a correlation between longterm success of TKA and restoration of near-normal limb
alignment. Malalignment of total knee prostheses has been
implicated in long-term difculties, including tibiofemoral
instability, patellofemoral instability, patellar fracture, stiffness, accelerated polyethylene wear, and implant loosening.
The use of accurate instrumentation and an understanding
of the basic principles inherent to the instruments are necessary to implant reproducibly well-aligned prostheses.
Computer-assisted navigation is being used by some surgeons to try to improve the reproducibility of component
alignment.
Normally, the anatomical axes of the femur and the tibia
form a valgus angle of 6 2 degrees. The mechanical axis
of the lower limb is de ned as the line drawn on a standing
long leg anteroposterior radiograph from the center of the
femoral head to the center of the talar dome (Fig. 6-14).
This mechanical axis typically should project through the
center of the knee joint, described as a neutral mechanical axis. When the mechanical axis lies to the lateral side
of the knee center, the knee is in mechanical valgus alignment. In mechanical varus alignment, the mechanical axis
of the limb lies to the medial side of the knee center. The
amount of varus or valgus deformity can be determined on
an anteroposterior radiograph by rst drawing the mechanical axis of the femur, a line from the center of the femoral
head to the center of the intercondylar notch, and extend-

Ch006-A03329.indd 249

249

90

Transverse
knee axis

Transverse
ankle axis
Fig. 6-14 Mechanical axis of lower limb extends from center
of femoral head to center of ankle joint and passes near or
through center of knee. It is in 3 degrees of valgus from
vertical axis of body. Anatomical axis of femur is in 6
degrees of valgus from mechanical axis of lower limb and 9
degrees of valgus from true vertical axis of body. Anatomical
axis of tibia lies in 2 to 3 degrees of varus from vertical
axis of body. (Redrawn from Moreland JR, Hanker GJ: Lowerextremity axial alignment in males. In Dorr LD, ed: The knee:
papers of the First Scienti c Meeting of the Knee Society, Baltimore,
1984, University Park Press.)

7/25/2007 11:46:46 AM

250

Part III Arthroplasty

mechanical axis, and the femoral articular surface is in a


corresponding 9 degrees of valgus. Multiple studies, including studies by Tew and Waugh, Jeffery, Morris and Denham,
and others, have shown that tibial components placed in
more than 5 degrees of varus tend to fail by subsiding into
more varus. Consequently, tibial components generally are
implanted perpendicular to the mechanical axis of the tibia
in the coronal plane, with varying amounts of posterior tilt
in the sagittal plane, depending on the articular design of
the component to be implanted. The femoral component
usually is implanted in 5 to 6 degrees of valgus, the amount necessary to reestablish a neutral mechanical axis of the limb.
Rotational alignment of total knee components is difcult to discern radiographically, making the assessment of
rotation primarily an intraoperative determination. The
rotation of the femoral component has effects not only on
balancing of the exion space, but also on patellofemoral
tracking. Because the proximal tibial cut is made perpendicular to the mechanical axis of the limb instead of in the
anatomically correct 3 degrees of varus, rotation of the
femoral component also must be altered from its anatomical
position to create a symmetrical exion space (Fig. 6-15).
To create this rectangular exion space, with equal tension
on the medial and lateral collateral ligaments, the femoral
component usually is externally rotated approximately 3
degrees relative to the posterior condylar axis. In a normal

3
Posterior
condylar axis

Fig. 6-15 To form rectangular exion space, after tibia has


been cut perpendicular to its axis, plane of posterior femoral
condylar cuts must be externally rotated approximately 3
degrees from posterior condylar axis. (Modied from Krackow
KA: The technique of total knee arthroplasty, St Louis, 1990,
Mosby.)

Ch006-A03329.indd 250

male femur, this technique rotationally places the femoral


component with the posterior condylar surfaces parallel to
the epicondylar axis. This technique fails when the posterior aspect of the native femoral condyle has signicant
wear, or when the lateral femoral condyle is hypoplastic,
as is frequently seen in knees with valgus deformity. In
these instances, the surgeon can use the epicondylar axis
or the anteroposterior axis popularized by Whiteside (see
Technique 6-1 for details). The epicondylar axis has been
shown in multiple studies to be difcult to determine in
vivo when comparing different observers and when comparing the measured axis with one determined by CT.
Each of these techniques of determining femoral component rotation is based on the geometry of the femur primarily, with subsequent ligamentous releases to create
symmetrical exion and extension gaps.
Knowledge of each of these techniques is necessary
because arthritic deformity or previous surgery may obscure
one or more of these landmarks. In revision TKA, the
epicondylar axis usually is the only native landmark left to
ensure proper femoral component rotation.
Two primary techniques are used to align the tibial
component rotationally. The rst technique aligns the
center of the tibial tray with the junction of the medial
third of the tibial tubercle with the lateral two thirds. The
second technique places the knee through a range of motion
with trial components in place, allowing the tibia to align
with the exion axis of the femur. This second technique
tends to align the tibial component rotationally with the
rotation of the femoral component, lowering the chance of
a rotation mismatch that could lead to accelerated polyethylene wear, although combined internal rotation of both
components may lead to patellofemoral maltracking, as
shown by Berger et al., and a higher incidence of patellofemoral pain, as described by Barrack et al.
Proponents of rotating platform designs claim that the
rotational freedom of the tibial polyethylene allows selfcorrection of minor malrotation of the tibial tray. Although
this factor may improve the congruency of the tibiofemoral
articulation, tracking of the patella is not improved, as
shown in a study by Pagnano et al. comparing rotating
platform TKA with a xed bearing, PCL-substituting
design.
Patellofemoral Joint
The primary function of the patella is to increase the lever
arm of the extensor mechanism around the knee, improving the efciency of quadriceps contraction. The quadriceps and patellar tendons insert anteriorly on the patella,
with the thickness of the patella displacing their respective
force vectors away from the center of rotation of the knee
(Fig. 6-16). This displacement or lengthening of the extensor lever arm changes throughout the arc of knee motion.
The length of the lever arm varies as a function of the
geometry of the trochlea, the varying patellofemoral contact

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251

Chapter 6 Arthroplasty of the Knee

ep

ric

ad
Qu

Patellar tendon

Extensor lever arm


Knee center of rotation

Fig. 6-16 Patella acts to lengthen extensor lever arm by


displacing force vectors of quadriceps and patellar tendons
away from center of rotation (COR) of knee. Length of
extensor lever arm changes with varying amounts of knee
exion.

areas, and the varying center of rotation of the knee.


According to Grood et al., the extensor lever arm is greatest at 20 degrees of exion, and the quadriceps force
required for knee extension increases signicantly in the
last 20 degrees of extension.
Patellofemoral stability is maintained by a combination
of the articular surface geometry and soft-tissue restraints.
The Q angle, as described by Hvid, is the angle between
the extended anatomical axis of the femur and the line
between the center of the patella and the tibial tubercle
(Fig. 6-17). The quadriceps acts primarily in line with the
anatomical axis of the femur, with the exception of the
vastus medialis obliquus, which acts to medialize the patella
in terminal extension. Limbs with larger Q angles have a
greater tendency for lateral patellar subluxation. Because
the patella does not contact the trochlea in early exion,
lateral subluxation of the patella in this range is resisted
primarily by the vastus medialis obliquus bers. As the
angle of exion increases, the bony and subsequent prosthetic constraints play a dominant role in preventing subluxation. In most current femoral component designs, the
lateral ange of the trochlea has been made more prominent, producing a more anatomical reconstruction.
Trochlear enhancements and attention to femoral component rotation, reproduction of preoperative patellar thickness, and maintenance of joint line height have improved
patellofemoral stability and have decreased the rate of

Ch006-A03329.indd 251

lateral patellar retinacular release signicantly. The application of these principles is discussed further in the section
on surgical technique.
As a consequence of its role in transmitting the force of
contraction of the quadriceps muscle to the patellar tendon
around a variably exed knee, the patella experiences a
joint reaction force as the trochlea opposes its posterior
displacement. This joint reaction force depends on the
angle of knee exion and the magnitude of the forces
transmitted to the patella from the quadriceps and patellar
tendons. During standing, the joint reaction force increases
with increasing knee exion as the force vectors of the
quadriceps and patellar tendons become more parallel to
the joint reaction force. Multiple investigators have calculated patellofemoral joint reaction forces of two to ve
times body weight during activities of daily living; during
squatting to 120 degrees of knee exion, the joint reaction
force may be seven to eight times body weight. These
forces in a normal knee are resisted by thick articular cartilage, but they may exceed the yield strength of polyethylene, leading to deformation of polyethylene patellar
components over time.
Many authors, including Aglietti et al., Hungerford and
Barry, and Huberti and Hayes, described variations in the
area of contact between the patella and the trochlea during
knee exion (Fig. 6-18). The inferior articular surface of
the patella rst contacts the trochlea in approximately 20
degrees of knee exion. The midportion of the patella

Q angle
To anterior
superior iliac
spine

Center of
patella

Tibial
tuberosity

Fig. 6-17 Q angle, as described by Hvid, is angle between


extended anatomical axis of femur and line between center
of patella and tibial tubercle.

7/25/2007 11:46:46 AM

252

Part III Arthroplasty

Lateral

Medial
120
0

Patellofemoral contact
zones change with knee exion.
(Redrawn from Aglietti P, Insall JN,
Walker PS, et al: A new patella prosthesis: design and application, Clin
Orthop Relat Res 107:175, 1975.)

Medial

Lateral

30

Fig. 6-18

60
90
90

60
30

120

articulates with the trochlea in approximately 60 degrees


of exion, and the superior portion of the patella articulates
at 90 degrees of exion. In extreme exion, beyond 120
degrees, the patella articulates only medially and laterally
with the femoral condyles, and the quadriceps tendon articulates with the trochlea. As discussed in the earlier section
on knee kinematics, the normal tibia internally rotates
during exion with greater posterior translation of the
lateral femoral contact point on the tibia relative to the
medial femoral contact point. The net effect of this internal
rotation of the tibia during exion is to centralize the tibial
tubercle in exion or diminish the Q angle. These relationships may be altered in TKA with nonanatomical patellofemoral geometry, malrotation of the femoral and tibial
components, elevation of the joint line relative to the tibial
tubercle, and patella infra from patellar tendon contracture.
Dennis et al. noted that with multiple designs of TKA they
tested, at least 19% in each group had a reverse rotational
pattern with deep knee bend.
Changes in the patellar area of contact with exion have
a signicant effect on the prosthetic patellofemoral joint.
As noted by Rosenberg et al., eccentric loading of the
patellofemoral joint leads to shear forces within the patellar
component and at the prosthesis-bone interface (Fig. 6-19).
Even if the mediolateral geometry of the patellofemoral
articulation is perfectly conforming, the inferior-tosuperior migration of the area of cont