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Postoperative: Surgical Complications (Stiffness, Graft Rupture)

Postoperative Stiffness Preoperative Consideration The goal of anterior cruciate ligament reconstruction (ACLR) is to stabilize a loose knee so the patient can return to desired activities, often involving pivoting and cutting. Additionally, many patients desire to return to competitive sports. ACLR is performed on a loose knee that either demonstrates or is at risk for instability. A knee that buckles or gives way does not allow…

Postoperative: Medical Complications (Deep Venous Thromboembolism, Infection)

Introduction Medical complications are uncommon following anterior cruciate ligament reconstruction (ACLR), yet their impact is not insignificant because of the frequency with which this procedure is performed. Further, these adverse events involve significant patient morbidity and represent a financial burden of over $1 billion annually, underscoring the importance of adequate management and prevention. This chapter will focus on the two medical complications most frequently encountered following…

Complications With Fixation Devices in Anterior Cruciate Ligament Surgery

Introduction Stable graft fixation is critical for a successful outcome after anterior cruciate ligament reconstruction (ACLR). The advantages of early joint motion and weight bearing after ACLR have been well documented. Anterior cruciate ligament (ACL) graft fixation must provide sufficient strength for rehabilitation and activities of daily living until biologic fixation takes place. The ultimate strength of all commonly used grafts in ACL reconstruction exceeds the…

Intraoperative: Surgical Technique

Introduction Modern techniques in anterior cruciate ligament reconstruction (ACLR) continue to evolve as surgeons endeavor to restore the anatomy and kinematics of the native knee. Among the reported complications associated with ACLR, tunnel malposition has been recognized as the most commonly observed technical error. , , Although errors in the femoral tunnel position are the most frequently reported technical errors in ACLR, tibial tunnel malposition can…

Intraoperative: Graft Harvest (Bone Patellar Tendon Bone, Hamstring Tendon, Quadriceps Tendon)

Introduction In this chapter, the potential complications during the harvest of hamstring, bone-patellar tendon-bone (BPTB), and quadriceps tendons for anterior cruciate ligament reconstruction (ACLR) will be discussed. Regardless of which graft is harvested and its potential complication, it is essential that the surgeon discuss these issues preoperatively with the patient. Hamstring Tendon Harvest Hamstring tendon autograft is one of the most common grafts used around the…

Preoperative: Graft Selection (Autograft vs. Allograft, Graft Choice)

Introduction Reconstruction of the anterior cruciate ligament (ACL) is a procedure that has increased in frequency in the United States, with more than 200,000 procedures performed annually. Despite the frequency with which it is performed, it is a procedure fraught with technical challenges. Graft failure and resultant recurrent instability can occur with all types of grafts. A review of board-collection data from the American Board of…

Preoperative Issues

Introduction Anterior cruciate ligament (ACL) ruptures are a common and potentially devastating injury in the athletic and active population. The incidence of ACL tears is rising in the United States, with recent estimates of 43.5 to 68.6 per 100,000 person-years. , Peak incidences occur in males aged 19 to 25 years (241 per 100,000) and females aged 14 to 18 years (227 per 100,000). , These…

Meniscus Transplantation

Introduction Initial treatment of most meniscus tears involves either excision or repair to prevent further propagation. The medial meniscus bears 40% of the tibiofemoral load, whereas the lateral meniscus bears 70% of the load. With a better understanding of the meniscal deficient biological environment, surgeons have transitioned in some case from removal to meniscal preservation. , If preservation is not possible, it is now understood that…

Meniscus Repair

Introduction The paradigm change in the operative treatment of meniscal injuries from meniscectomy to repair when possible has significantly transformed the management of these injuries. A better understanding of the important roles of the meniscus and the devastating consequences of complete or extensive partial meniscectomy, as well as the introduction of new techniques and sophisticated devices for meniscus repair, , , , may all play a…

Partial Meniscectomy

Introduction Knee arthroscopy is one of the most commonly performed procedures in the United States, with partial meniscectomy reported as the most frequently performed arthroscopic procedure. Arthroscopy is a minimally invasive procedure with low morbidity; however, complication rates have been reported to range from 1% to 8%. , These complications vary in severity and can lead to significant alterations in a patient’s postoperative course and rehabilitation.…

Complications in Lower Extremity Soft Tissue Surgery in Neuromuscular Patients

Introduction Soft tissue pathology in the lower extremities of children with neuromuscular diseases, particularly those with spasticity (most commonly cerebral palsy [CP]), can lead to significant impairment in gait in ambulatory children and function-limiting deformities affecting limb and trunk position in nonambulatory children. The deformity and gait disturbances that stem from spasticity and contracture can be debilitating, often necessitating surgical intervention. Depending on the child’s clinical…

Complications of Upper Extremity Surgery for Neuromuscular Disorders

Introduction Cerebral palsy (CP) is a static, nonprogressive encephalopathy, with an incidence of approximately 1 to 3 per 1000 births. CP represents a wide spectrum of possible motor, sensory, and cognitive impairments, and CP movement disorders are generally classified as ataxic, dyskinetic, spastic, or mixed. Spasticity is focused on because it is the most responsive to surgical treatment. Upper extremity involvement is typical in patients with…

Spastic Hip Dislocation

Introduction Cerebral palsy is the most common neuromuscular disorder cared for by orthopedic surgeons. It has an incidence of 2 to 3 per 1000 live births, which has not changed dramatically in the last 50 years. The cerebral palsies are a group of disorders caused by an insult to the developing brain in the prenatal and postnatal period until the age of 2 years. Causes include…

Osteotomies for Osteogenesis Imperfecta

Introduction Osteogenesis imperfecta (OI) presents unique challenges for the orthopedic surgeon. This hereditary defect in type I collagen can vary in its manifestations from mild to severe. Depending on the type and severity of OI, treatment may range from medical management and routine fracture care to deformity correction with complex realigning osteotomies. Management can be fraught with complications without careful preoperative planning and intraoperative attention to…

Cavus Foot Correction

Introduction Cavus foot deformity is a difficult and complex problem to solve for the orthopedic surgeon. This is especially true in the pediatric population, where the deformity is often the result of a neurologic condition. At its core, cavus deformity is one derived from soft tissue and muscle imbalance resulting in plantarflexion of the first ray and elevation of the medial longitudinal arch, with either flexible…

Tarsal Coalition Resection

Introduction Tarsal coalition is a congenital anomaly consisting of aberrant osseous, fibrous, or cartilaginous bridging between the tarsal bones. The reported incidence of tarsal coalitions is 1% to 13%, with bilaterality in nearly 50%. Calcaneonavicular coalition was found to be the most common type (53%), followed by talocalcaneal coalition (37%), and together they account for 90% of all tarsal coalitions ( Figs. 36.1 and 36.2 ).…

Complications in Pediatric Flatfoot Reconstruction

Introduction Flatfoot is a normal shape of the human foot from birth through old age. It is seen in most infants and approximately 20% to 25% of adolescents and adults. Flexible flatfoot (FFF) is the subtype seen in essentially all affected infants and approximately 64% of flatfooted adolescents and adults. It does not cause pain or disability. FFF with a short tendo-Achilles (FFF-STA) accounts for approximately…

Surgical Management of Clubfoot

Introduction Clubfoot deformity, while one of the most familiar congenital orthopedic conditions presenting for early intervention, can pose numerous treatment challenges to even the seasoned pediatric orthopedic surgeon. Though nonoperative management with serial casting is currently the gold standard of care during infancy, surgical intervention is still occasionally required to obtain a painless, functional, and plantigrade foot for recurrent or resistant deformities. Although there is no…

Complications Associated with Epiphysiodesis and Hemiepiphysiodesis

Introduction Angular limb deformity and limb length discrepancy (LLD) are among the most commonly treated pediatric orthopedic conditions and have potential for significant physical, social, and psychological effects on children and their families. Whereas classic treatment of LLD and angular deformity focused on bone-shortening operations and osteotomies, procedures aimed at altering physeal growth, both permanently and temporarily, have become commonplace since initial introduction of the concept…