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The table should allow good anterior and posterior views to be obtained with fluoroscopy. A Keith needle is inserted into the physis (this characteristically feels like pushing a needle into a bar of soap), 3. The ideal lateral projection with femoral neck, femoral shaft, and guidewire coplanar improves accuracy and consistency. Flexion of less than 90 degrees and a flexion contracture of more than 15 degrees are considered pathologic. In older children and teenagers with a longstanding jump or crouch gait pattern, lengthening of the hamstring muscles alone may not result in complete knee extension when the hip is placed in extension. The sciatic nerve may also be compressed under the tendon of the gluteus maximus during surgery if the hip is maintained in severe flexion and internal rotation. Cementless hemispheric porous-coated sockets implanted with press-fit technique without screws: average tenyear follow-up. The lateral cutaneous nerve emerges from the lateral border of the psoas major at about its middle, and crosses the iliacus muscle obliquely, toward the anterosuperior iliac spine. The vastus lateralis is reflected from its proximal and posterior origins and elevated to expose the proximal femur subperiosteally. However, cementless reconstruction is widely used and is not associated with an increased risk of infection. Chapter 13 Flexible Intramedullary Nailing of Femoral Shaft Fractures Gilbert Chan and John M. The asynchronous rate of longitudinal growth in an anatomic region where two bones are paired in close longitudinal relationship leads to a greater risk of anatomic distortion. In patients who require surgery, we feel that ulnar-tether release, with or without exostoses excision, with or without radial osteotomy, provides the most reliable result with the fewest complications. Alignment is checked after placement of the first screw both radiographically and by physical examination. This helps avoid unnecessarily long cement mantles that are difficult to remove at revision, and it enhances cement pressurization. The posterior elements of L5 and S1 are removed (the posterior elements of L4 are removed if needed). For patients close to skeletal maturity, interfragmentary fixation can be used with or without a one-third tubular plate just as in a skeletally mature patient. The affected extremity should be checked to ensure that there is no vascular or neurologic injury. The additional stress placed on the adjacent vertebrae below the level of fusion may result in instability with time. Before reaching that point, the osteotome is withdrawn, and the remaining bone bridge is broken off. A 12-degree varus deformity is shown with planning for a 12-degree opening wedge oblique osteotomy with a 10-mm opening at the base. Additional freehand cleanup may be carried out to improve bone-to-component apposition in all of the illustrated techniques. By taking serial radiographs and noting the appearance of bone metastases, it is possible to follow the progress of treatment with systemic hormone therapy or chemotherapy agents plus local radiation therapy. Pinning Once a reduction has been obtained, the fracture is fixed with smooth Kirschner wires. Anteriorly, the fibers of the rectus femoris tendon traverse the patella and insert on the tibial tubercle inferior to the patella as the patellar tendon. A 7- to 10-mm bone chip is recommended,1 in contrast to the smaller bone graft size used with femoral impaction grafting. The pedicles are cylindrical structures that bridge the posterior elements of the spine with the vertebral body. The axillary nerve wraps around the humerus to insert into the deltoid, roughly 5 cm distal to the acromion.

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Selection of a cemented-type metaphyseal stem may require step-cementing of the stem and tibial base plate, with no cement applied to the ongrowth surfaced metaphysical cone. It should not be necessary to remove significant bone, because the indication for use of this device is severe bone loss. Failure to obtain a satisfactory closed reduction may require an open reduction, and surgeons should be familiar with this technique as well. Macnicol and Gupta14 reported 35 cases of epiphysiodesis in which a cannulated tube saw was used to ablate the physis. Repeat assessment of the popliteal angle is made after lengthening of the medial hamstring muscles. Cubitus varus Unstable fractures treated nonoperatively can displace proximally and laterally, allowing the elbow to drift into a varus position. The appropriate incision for the surgical approach must be used with an adequate (6 cm) skin bridge. The medial approach described by Ludloff3 accesses the hip in the interval between the pectineus and the adductor brevis. In older patients with advanced disease, however, the side effects of the drugs may be too severe. The preferred half-pins are hydroxyapatite-coated and are inserted so that the thread distance is the same as the diameter of the bone. Care must be taken with interpreting the images, however, because bone edema can be misinterpreted as osteomyelitis and result in too aggressive a resection. Various combinations of augments and polyethylene liners should be tried until the optimal combination is found; this may take a considerable amount of time to achieve. In other cases, a coronal plane deformity resembling clinodactyly may be present, although a causative relationship has yet to be established. Advantages More familiar and traditional approach Conversion to open procedure is easy. The usual plate length is from 10 to 16 holes, depending on the fracture location and patient size. Alternatively, the second nail may be inserted immediately after the first nail to the level of the fracture site. Slightly incomplete coverage of the acetabular component (up to 20%) may be acceptable. The patient is allowed full weight bearing once two of four cortices are present on the radiographs. Intramedullary reaming should be carried to the depth of the stem available in the revision system in use. Definitive stabilization is then obtained at the first tarsometatarsal joint with 3. At this point, the acetabulum is exposed, and the femoral head can be removed again with a corkscrew and a Cobb elevator. With tension applied to the tendon at the distal exposure, a safe identification of the origin has been simplified. Subcutaneous flaps can be elevated to allow great mobility of the prepatellar skin to limit the size of the incision. Increased anteversion along with coxa valga is a component of the abnormal proximal femoral anatomy in longstanding cases of congenital, developmental, or neurogenically acquired hip dislocations.

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The incision is made over the rib and subperiosteal dissection is carried out circumferentially around the rib after sequential dissection through the musculature. Check notching with the stylus several times during femoral preparation, especially in the anterior and superior portion of the femoral head, which is the most vulnerable for notching. Postoperative sepsis has been reported to range from 2% to 20% and may be more common with the posterior surgical approach. A negative hip aspiration may indicate that the infection is in the acetabulum, proximal femur, or pelvis and has not yet decompressed into the hip joint. Bipolar sealing of epidural vessels that lie on the medial aspect of the pedicle and down on the inner wall of the body will aid in controlling blood loss and improving visualization. Cementless bipolar hemiarthoplasty for displaced femoral neck fractures in the elderly. Ankle range of motion is now increased to 10 to 15 degrees of dorsiflexion with the knee extended. Full range of motion starts 1 to 2 weeks postoperatively, and patients are advanced to plyometrics at 6 weeks postoperatively. All tissue lateral to the psoas tendon can be removed at this point if needed to allow visualization of the stem. A local kyphotic or lordotic deformity may occur with hemivertebra if the associated failure of formation is greater anteriorly or posteriorly. Physical therapy is restarted 1 month after frame removal and Rush pin application. To mark the rotation, we use a sharp osteotome to scratch the distal femoral cortex once the trial component is appropriately positioned. The radial nerve enters the anterior compartment of the arm in the distal third of the upper arm and travels between the brachialis and brachioradialis over the anterolateral distal humerus before it enters the supinator muscle in the proximal forearm. If there is only a small metaphyseal fragment, medial malleolar fractures can be fixed with compressive screws placed within the epiphysis, parallel to the physis. The use of a modified V-Y quadricepsplasty during total knee replacement to gain exposure and improve flexion in the ankylosed knee. Did the patient have severe pain postoperatively that limited his or her ability to perform physical therapy Does the patient have hypersensitivity of the skin overlying the incision or other complaints that suggest neurogenic pain or a chronic regional pain syndrome Wound drainage that persisted for more than a few days after surgery the use of antibiotics for more than 24 hours postoperatively Persistent pain that is of a different character than the pain the patient had before the surgery Inspect the skin for the presence of a past or present sinus, indicating infection. If more of the medial wall is left intact, then the fulcrum of rotation will move more anterior and more lateral coverage will be obtained. In spastic hemiplegia due to cerebral palsy, the most common peripheral manifestations in the upper limb are shoulder internal rotation, elbow flexion, forearm pronation, wrist flexion and ulnar deviation, finger clenching or swan-necking, and thumb-in-palm deformity. Antegrade versus retrograde titanium elastic nail fixation of pediatric distal-third femoral-shaft fractures: a mechanical study. If more lateral coverage is required, then the osteotomy is inclined laterally and both cuts begin a little farther away from the capsule. Recent retrospective studies suggest that a delay in treatment of the majority of supracondylar fractures is acceptable. The goal should be to restore the normal contour and anatomy of the proximal tibia to provide a stable platform for the revision tibial component. The femora that gained more length (expressed as percentage of original length) had poor healing indices. If the tibia is chosen, the incisions are placed anteriorly and medially to obtain access to the lateral cortex and posteromedial cortex, respectively. Previously, feeler gauges have been used to measure the gaps, because they do not stretch the ligaments. Chapter 67 Anterior Approach for Open Reduction of the Developmentally Dislocated Hip Richard M. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. Usually at the costochondral level at the 10th rib, access into the retroperitoneal space is quite easy, with retroperitoneal fat evident.

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Positioning the patient is positioned according to surgeon preference and in accordance with the surgical approach. A chest pad attached to the table prevents the patient from being pulled off the table inadvertently when traction is applied to the arm. Their mid-term report was a follow-up of their short term study of 28 knees in 25 patients. Milch type I fractures (the less common) traverse the metaphysis and physis as well as extend across the ossification center of the lateral condyle. The new femoral component is cemented into place separately, and the cement is allowed to harden under direct vision. The fracture site is exposed and a rectangular area is outlined in the bone using drill holes. Most patients commonly present for low-grade back pain and not for radicular symptoms. The dissection is carried deeper until the periosteum of the mastoid process is exposed. This directly exposes the superomedial fragment and keeps the neurovascular bundle in the anterior flap. Femoral dowel for nonarticulating spacer Mixing antibiotics into cement When mixing high-volume antibiotics into cement, depending on which antibiotics are used (eg, Nebcin [tobramycin], which is a very high-volume powder), the handling properties can become difficult because of poor viscosity. If complete knee extension has been achieved after lengthening of the medial hamstring muscles and transfer of the rectus femoris muscle, then the knee is protected in a knee immobilizer after surgery. The osteotome is directed down to the triradiate cartilage but does not enter the cartilage. Anterior release is also recommended for severe hyperlordotic and hyperkyphotic spinal deformities. The amount of tibial bone resected is kept to a minimum, but it must be of adequate thickness to allow implantation of the components and insertion of polyethylene without elevating the joint line. The proximal part of the distal clamp is approximately angulated by 10 to 15 degrees anteriorly. Disruption of circulation to the talus correlates with open or comminuted talus fractures, leading to an increased risk of avascular necrosis. Hematogenous inoculation of the joint with bacteria also may occur in the face of a previously well-functioning prosthesis. Femoral preparation and component placement are performed in a similar systematic fashion. Clinical determinants of the outcome of manual stretching in the treatment of congenital muscular torticollis in infants. Once cup verification has been finished, the pelvic reference array, bone fixator, and two pins are removed, and femoral preparation proceeds. Also, impaired tissue development and growth due to decreased innervation and physiologic stresses can create a barrier to normal healing. Muscle shortening may recur and is usually effectively treated with a period of home- or community-based stretching exercises. Over 99% of cases occur on the lateral side of the knee, with an overall incidence of 1% to 15% of the general population. Patients with migration indexes over 50% generally will benefit from surgical treatment of their dysplasia, which can include a femoral or pelvic osteotomy. Prone position with halo fixed to Mayfield positioning device (Integra Corporation). The line of incision along the proximal femur demarcated relative to the top of the greater trochanter. Scanograms can then be obtained to determine leg-length inequality, which can be corrected by lengthening with the fixator. A small elevator is used to visualize the surface of the capsule before entering it with a no. The stockinette is unrolled to the level of the midthigh and secured with a Coban dressing (3M).

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The guide pin normally is inserted from the superior part of the femoral head about 1 to 2 cm above the fovea. Unstable or comminuted fractures require waiting until visible callus is present before weight bearing. A common dilemma for parents and consulting physicians is an unwillingness to commit to a path of either multiple lengthenings or early amputation. Between the blood-filled spaces are fibrous septa containing giant cells and immature bone. If a Grammont procedure4 is to be performed, the incision is extended past the tibial tuberosity along the crest of the tibia so that the proximal periosteum is elevated as described above. The medial patellar approach provides excellent exposure and is associated with a very low incidence of tibial or femoral complications. Irrigation fluid is placed in the surgical site and positive pressure applied to check for pleural leaks. Titanium elastic nailing of fractures of the femur in children: predictors of complications and poor outcome. In the more common scenario of subluxation, passive flexion is limited but improves with splinting, casting, or both. Long-term monitoring of these patients and constant improvement in instrumentation are necessary to ensure optimal development, comfort, and function in this patient population. Arthrotomy can be performed by the medial parapatellar approach, the subvastus (Southern) approach, or the midvastus approach. Once one bone is successfully reduced and stabilized via indirect techniques, achieving the same for the second bone will be more difficult. The surgeon should avoid fixation that crosses the physis, particularly across the lateral distal femoral epiphyseal plate, which seems to have the greatest risk of producing a growth disturbance. The pin is advanced into the head, stopping several millimeters below the subchondral bone. There may be concomitant limb-length discrepancy with both true and apparent foreshortening of the involved limb. The optimal pharmacologic prophylaxis remains a matter of debate, but some form of prophylaxis should be continued after hospital discharge. Insults that breach the physical separation between metaphyseal and epiphyseal trabecular bone, that significantly compromise epiphyseal blood flow, or that critically injure the resting or proliferating cell layers may result in physeal bar formation. In the presence of acetabular dysplasia, internal rotation of the hip often is increased because of excessive anteversion of the femoral neck. The frame is removed in the office or the operating room after healing is noted radiographically. The muscle belly is reflected distally off its proximal origin, allowing easy access to the lateral capsule of the talus. Modest femoral neck lesions may be stabilized with a reconstruction nail, with the exception of renal cell and thyroid carcinoma, in which cases arthroplasty is recommended. The arthroscope is placed on the outer border of the radiocapitellar joint and angled to allow a complete view of the capitellum and radiocapitellar interval. The remainder of the plate is left flat to prevent varus displacement of the tuberosity. May be exacerbated by combining flexion, adduction, and internal rotation Occurs after the person has been sitting for a long period the "C sign" is diagnostic: the patient places the index finger over the anterior aspect of the hip and the thumb over the posterior trochanteric region to indicate the location of their pain. Conventional surgical reconstruction techniques risk potential iatrogenic growth disturbance due to physeal violation, and thus special consideration must be given to this patient population. In skeletally immature children, the guide pin should be 4 to 5 mm distal to the growth plate. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. Finally, a 4-mm half-pin, or transfixion pin, is advanced from medial to lateral, bicortically, through the tuberosity of the calcaneus. The interface of the femoral, tibial, and patellar components with bone must be visualized. Neck fractures that cannot be reduced closed will need to be openly reduced by a Watson-Jones approach. The vertical distance between the center of the acetabular component and the center of the the prosthetic head represents the anticipated change in leg length-we seek an increase in leg length of 2 to 5 mm in most cases.

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Most of the longitudinal growth of the ulna occurs at the distal physis,16 which is also the more commonly affected physis (30% to 85% of the cases). Radiographs of the lower extremity should be performed with the patellas directly anterior and also with the legs maximally externally rotated. The biceps femoris muscle has a relatively large physiologic cross-sectional area and a relatively small ratio of tendon length to muscle fiber length, indicating that it is designed for minimal excursion and increased force generation. Once the patient is adequately anesthetized and a Foley catheter is inserted, he or she is placed in the desired position in a gentle, organized fashion. Pins left protruding distally may provide a portal to seed the knee joint with bacteria. Because of the possibility of bilateral involvement, both thumbs should be examined. Once all of the pedicle screws have been placed, a gentle reduction is performed, aimed at correcting the slip angle. Pulmonary function during and after total hip replacement: findings in patients who have insertion of a femoral component with and without cement. General recommendations for titanium elastic nails are: Children at least 5 years old (ideal for children 6 to 12 years of age) Fractures of the middle 70% of the diaphysis Length-stable fracture patterns. It has been said that you need only a thumb to test the motor function of all three major nerves: radial nerve extensor pollicis longus, ulnar nerve adductor pollicis, median nerve opponens pollicis. The splint can be extended up to the buttocks to support the femur, and loosely overwrapped with an elastic wrap. The solid arrow shows the intact cartilage side and the open arrow shows the osteochondritis dissecans side. Others16 have reported improvement in triggering with nighttime splint treatment averaging 10 months, but in a series that included trigger fingers, there was a 24% drop-out rate and there was no control group. Computed tomography shows bone well and is most helpful to evaluate hip incongruity during the late stages of remodeling and during young adulthood. The leg-length discrepancy is calculated by subtracting the value measured for the nonoperative hip from the value obtained for the operative hip. A thorough examination will include the following: Examination for effusion Patellar stability testing. Once the stem is stable within the femoral canal, a trial reduction can be performed to assess leg lengths and stability. If the fibula is significantly fractured and shortened it is important to either anatomically reduce or reduce and internally fix the fibula to obtain an appropriate template for the anatomic length of the ankle mortise. The calcaneus is fractured by a combination of shear and compression forces generated by the talus descending upon the calcaneus. Bone transport with a fixator allows the limb to remain at a desired length (1 cm shorter than the contralateral limb) and fills the gap with healthy bone from the proximal tibia or femur. This fixator allows gradual or acute correction of deformity in two planes of angulation, two planes of translation, rotation, and lengthening without the disadvantages of a ring fixator. The patient undergoing the initial femoral lengthening is positioned supine on the operating table with a radiopaque grid placed under the operating table pad. The choice of any surgical approach or technique should always have the goal of total anatomic restoration, although extreme comminution can compromise attainment of this goal. Two pins are drilled from medial to lateral along the osteotomy line to intersect the initial guide pin 1 cm from the lateral cortex. To truly avoid weight bearing, the cast must be flexed at least 70 to 80 degrees (if appropriate for a specific fracture). The lateral nail (nail entering through the lateral cortex of the femur) should end at the apophysis of the greater trochanter. Pemberton osteotomy depicted on a bone model viewed from anteriorly (A), from inside the pelvis medially (B), and from outside the pelvis laterally (C). Spinal Muscular Atrophy this condition is an autosomal recessive disorder resulting in spinal cord anterior horn cell degeneration.


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Displaced fractures of the talar head have a 10% incidence of osteonecrosis and can lead to secondary posttraumatic arthrosis. The osteotomy is bicortical only in the area of the iliac spines and the sciatic notch. Although the published series of medial open reductions vary in the likelihood of avascular necrosis, it is clear that the proximity of the medial femoral circumflex artery to the medial hip capsule places the hip at greater risk for avascular necrosis during this approach compared to the anterior open reduction. The periosteal extension of the tendon is elevated with the tendon so that the detached tendon remains tethered distally. There may be a higher incidence of heterotopic new bone formation, and decreasing abductor muscle function often is compromised following this approach. It allows for large corrections of the osteotomized fragment in all directions that are needed, including lateral rotation, anterior rotation, medialization of the hip center, and version correction. If the blade is placed to far posteriorly, the deep branch of the medial femoral circumflex artery can be injured. Reduction is obtained by reaching into the fracture site with a hemostat and getting hold of the cut edge of the periosteum. Once the two screws are inserted, the remaining screws can be placed in a locked mode. Surgical management should be considered for fractures associated with nerve, vascular, or soft tissue injuries that would preclude standard casting. The pubofemoral ligament, which covers the inferior and medial aspect of the hip joint capsule, tightens with hip extension and abduction. Routine screening for hip dysplasia in neuromuscular conditions with radiographs is widely performed. After the graft has been passed under the lateral collateral ligament and over the intramuscular septum, it is pulled through the subperiosteal tunnel, through the posterior joint capsule, and out the tibial epiphyseal tunnel. There should be at least 2 cm of intervening bone between the screw and the fracture. Alternately, both nails are inserted from the same side to avoid compromised skin (B). Flexion of the distal interphalangeal of the index finger and the interphalangeal of the thumb herald flexor digitorum profundus and flexor pollicis longus function of these digits. Once fixation of the fracture has been achieved, stability is tested by gentle flexion and extension of the knee. When forming surgical indications, the surgeon must consider the available data regarding the natural history and the outcomes of conservative treatment outlined above and must discuss the options with the family. Ogilvie and King17 used a low-speed, high-torque drill to create an epiphysiodesis in seven children. The anterior third of the vastus lateralis is incised longitudinally using electrocautery, beginning at the trochanteric ridge and extending 2 to 3 cm beyond. Fortunately, most motor deficits will improve with time, although improvement and recovery may take several months. Growth plate Corticotomy site Ilizarov Frame Application 1 3 3 For simple lengthening (without deformity), three rings (or two rings and one arch) are used. Tibial tray augmentation with modular metal wedges for tibial bone stock deficiency. Proper nail contouring and size selection are important to maintain stability of the fracture. The leg is prepared and draped in the standard sterile fashion for joint replacement surgery. If the fracture does not heal, open reduction with bone grafting may be necessary. We do not advocate stress radiographs in children; however, we will use a external rotation stress view intraoperatively to evaluate for syndesmosis injury if suspected in children near skeletal maturity. The patient is subsequently converted to a short-leg non-weight-bearing cast for 6 weeks, followed by progressive range of ankle and subtalar motion and return to weight bearing in a removable fracture-boot. An anterior midline incision is preferred, but it may be necessary to use the most lateral incision to protect the patient from skin necrosis in areas between incisions. Both allow for minimal access to the articular surface such that complex intra-articular injuries are not well addressed through these approaches alone. While simple falls are a frequent cause of hip fractures in the elderly, they are less common in children.

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These studies, in combination with a well-planned biopsy, will reveal the primary cancer for most patients. Preoperative Planning If manipulative reduction is contemplated, the surgeon should request muscle relaxation from the anesthesia provider after induction. Labral disease commonly involves this region of the acetabular rim and often includes a degenerative, intraarticular tear with an intact capsular attachment. The component must be cemented in the appropriate version, and the neck of the prosthesis must sit on the femoral neck, which can be additionally prepared with a calcar planer. Minimal axial or rotational bone deformity, asymmetric bone shortening, or ligament instability can hinder this function. Grissel syndrome: torticollis associated with retropharyngeal abscess or post-tonsillectomy status. When drilling pins retrograde, it is important to avoid the nerve and vascular structures in the posterior aspect of the distal thigh. The relative cross-sectional area of the bar is important because physeal bars occupying greater than 50% of the cross-sectional area of the physis have a less favorable result after resection. The trocar is inserted into the soft tissue guide and seated onto the femur perpendicular to its long axis. Care is taken to use a posterior starting point to avoid the posterior interosseous nerve. Comminuted fractures that are not amenable to screw fixation may benefit from a small buttress plate or a "suture tension band" technique using the deltoid ligament for fixation. This analysis found no evidence of excessive early migration or loosening of the components. Osteotomy of the anterior superior iliac spine preserving the attachments of the sartorius muscle and the ilioinguinal ligament. Preoperative radiograph of a 13-year-old girl with a right thoracic curve measuring 52 degrees from T6 to T12. After a rasp is used to create a groove in the anterior tibia, under the intermeniscal ligament, a curved clamp is placed under the intermeniscal ligament (F) and the graft is brought to the anterior aspect of the knee. Lumbar pedicle screws start at the junction of the pars interarticularis, the midpoint of the transverse process, and the base of the superior articular process. If there is a significant gap between the fracture fragments, the distraction is released and the surgeon gently impacts the fracture fragments together. The key to treatment is the persistent complaint of instability feelings and examination consistent with instability with or without pain. Extensive periosteal stripping of fracture fragments is avoided and fragments are carefully hinged on their soft tissue attachments to preserve their vascularity. Excellent functional outcomes were observed in those cases where a solid fusion was achieved. Acetabular osteotome systems facilitate cup removal by using the center of the acetabular polyethylene as a reference for osteotome insertion. A functional outcome study of 134 cerebral palsy patients treated surgically showed that the average functional improvement was from use of the hand as a poor passive assist to use of the hand as a poor active assist. Return to full activity, especially competitive athletics, is allowed only when complete healing is observed on radiographs in three planes: anteroposterior, lateral, and oblique. Published reports suggest that bipolar hemiarthroplasty has poor outcomes when used as a primary prosthesis for failures with degenerative joint disease, and this technique currently is not recommended. A thin layer of cement is added to the tibial tray, and the tibial component and polyethylene liner are impacted into place. This is accomplished by meticulous removal of the soft tissues and judicious contouring of the bony surfaces: removing too much bone can weaken hook purchase, whereas removing too little bone can result in improper seating of the hook. The lateral compartment should not measure less than 5 mm (the sum of the thickness of the normal cartilage), and the medial compartment should gap at least 5 mm (the sum of the articular cartilage lost). The resected fragment of tibial bone demonstrates anteromedial osteoarthritis and intact posterior cartilage. Painless clicking can occur as the iliopsoas tendon snaps over the uncovered anterior femoral head, an occurrence that may be associated with dysplasia. Two additional rods are then placed, one on either side of the spine, connected to the corresponding screws.

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Surgical treatment of femoroacetabular impingement: evaluation of the effect of the size of the resection. This limits the period of the load carried by the plate and the potential for failure. The capsule must be separated from any false acetabulum on the lateral iliac wall. This is the deep fascia, which can then be further exposed distally by using a sponge on the fascia. Diminished strength may indicate nerve damage or compartment syndrome or may also be secondary to pain. After incision of the costochondral junction, the retroperitoneal fat is visualized and the retroperitoneal cavity is entered. Injury to the cutaneous nerves is common, and patients should be warned of this risk. The posterior column starts from the articulation of the superior gluteal notch with the sacrum and extends through the acetabulum and ischium to the inferior pubic ramus. In a series of 600 resurfacings, five femoral neck fractures occurred (incidence 0. All failures were related to repeat trauma occurring at least 4 years from the index surgery. However, if insufficient growth remains for hemiepiphysiodesis to be effective, osteotomy is the best option for correction of the deformity. Insert the trial components and check the balance of the knee after each step of the procedure. In tibia the mean tibial lengthening was 9 cm or 41% of the original tibial length. This phenomenon may represent a volar plate or capsular contracture of the interphalangeal joint from a prolonged locked flexion posture. In the case of an open posterior arch, meticulous and blunt dissection should be used to keep from injuring the dura mater and the cord. At 6 to 8 weeks after the injury, progressive weight bearing, range of motion, stretching, and strengthening are initiated. One of the primary goals of physical therapy is to maintain knee extension and to continue to obtain knee flexion. Results of this test are meaningless unless compared to the preoperative findings, as some hips have a positive Ober test preoperatively. The selected trial is removed from the tibia and left assembled as a model for assembly of the final components. A lateral release is performed about 1 cm lateral to the patella, extending from the proximal tibia to 1 cm above the proximal patella. A spinal needle is used to identify the level of portal before making the incision. After completion of the neck fracture, continued hyperdorsiflexion and axial load to the body of the talus may force dislocation of the talar body posteriorly, disrupting significant extraosseous circulation. Children younger than 6 years of age with marked collapse of the femoral epiphysis: Typically children below 6 years of age heal well without treatment, but in severe cases, treatment may be indicated. If there is severe bowing of the tibia, an osteotomy may be needed to prevent eccentric reaming, as in this patient. This allows the surgeon to rotate the broach if necessary to improve filling of a proximal metaphyseal defect. These procedures can be performed under spinal or combined spinal and epidural anesthesia, because hypotensive anesthesia can have the benefit of reducing blood loss. Preoperative Planning All imaging studies obtained before surgery should be reviewed. With a Kocher clamp, grasp the proximal aspect of the reflected head of the rectus femoris tendon to further expose the capsule. Broaching is begun with the smallest broach and then increased until appropriate fit and fill is achieved.

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An adhesive drape is put in place distal to the tourniquet to prevent antimicrobial solutions from dripping under the tourniquet. The top line marks the epicondylar axis, and the bottom line marks the posterior condylar line; the component in this case is internally rotated. Evaluation and treatment of infection at the site of a total hip or knee arthroplasty. The patient is then seen at the office at 6 weeks and 6 months after surgery and then routinely followed every 3 years. After a short incision near the base of the anterior neck, the remaining cuts should be performed with an inside-out technique. Rarely, it may be necessary to perform an osteotomy to extract particularly difficult stems. Either of two types of connectors may be used: a tandem connector, which houses the cranial and caudal rods inside a rectangular box so the ends meet end to end, or side-to-side connectors, which allow the rods to overlap. The fracture boot should be worn during the night for the initial 3 to 4 weeks after surgery to prevent an early Achilles tendon contracture. The capsule and synovium around the femoral neck are preserved as much as possible to prevent further vascular damage to the femoral neck and head. A complete assessment of neurovascular status of the upper extremity is performed, with particular attention to the ulnar nerve examination. Weight-bearing anteroposterior and lateral views can be helpful to load the knee and show the component position of maximum subsidence as well as resultant limb. Intra-articular injections Corticosteroid injections in knees with considerable inflammatory component (eg, swelling) are useful. Use of a longer guidewire can help to avoid capturing the guidewire in the reamer. Femoroacetabular impingement is caused by overcoverage of the acetabulum (ie, retroversion). Laboratory studies, including a complete blood cell count with differential, erythrocyte sedimentation rate, and C-reactive protein, should be obtained. The last impactor should be approximately 4 mm larger than the acetabular cup to be placed. With fixation of the Lisfranc joint, the screw must angle slightly dorsally (relative to the plantar foot) to accommodate the normal "Roman arch" configuration in the coronal plane. If the distal tibial physis is closed, the dissection can be extended beyond the physis and to the epiphysis if needed. If the fracture remains nondisplaced, long-arm casting is continued for another week and then repeat radiographs are obtained. During reduction, the nerves of the brachial plexus may become entrapped between the clavicle and the chest wall. Reduction is adequate if the following criteria are fulfilled: the anterior humeral line crosses the capitellum. In smaller, thin patients it is possible to grasp the head through the axilla to assist with the reduction. Cardiac auscultation should be done, because 20% of patients with congenital scoliosis have congenital heart anomalies. Complications have been reported while treating these complex fractures with other methods of fixation, such as titanium elastic nails or external fixation. Additional sources of ankle malalignment include both bony and ligamentous disorders. The Kirschner wires are left protruding from the skin and are bent to prevent migration of the pins underneath the skin. There probably is a genetic component that provides a susceptibility to develop scoliosis. Some implants have trials with slots, which allows for more precise sizing and preparation for modular augments. Patients with severe patellofemoral arthrosis and patellofemoral pain syndrome may not benefit from these procedures. Acetabular deficiencies may be extensive in the face of polyethylene wear and osteolysis. The role of intraoperative Gram stain in the diagnosis of infection during revision total hip arthroplasty.

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