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General Principles of Infection

Etiology Bone and joint infections pose a formidable challenge to the orthopaedic surgeon. The high success rate obtained with antibiotic therapy in most bacterial diseases has not been obtained in bone and joint infections because of the physiologic and anatomic characteristics of bone. Approximately 80 million surgical cases are performed in the United States yearly, and with the rise in aging population, this will most likely…

Amputations of the Hand

Acute fingertip and thumb injuries are common and require prompt and meticulous composite soft-tissue repair in incomplete amputations. Complete amputations proximal to the eponychial fold in the thumb or multiple digits may be salvaged by microvascular techniques (see Chapter 63 ); however, more distal devascularizing injuries rarely can be salvaged by such means and usually require special composite soft-tissue coverage techniques or complete amputation. In general,…

Major Amputations of the Upper Extremity

Many orthopaedic surgeons consider amputation as a failure to restore function to an individual; however, an amputation should be considered the start of rehabilitation. Major amputations of the upper extremity are classified as being from the wrist distally to the axilla proximally. Major amputations of the upper extremity account for 8% of all amputations and are approximately 20 times less common than amputations of the lower…

Amputations of the Hip and Pelvis

Hip disarticulation and the various forms of hemipelvectomy most often are performed for the treatment of primary bone tumors and rarely for metastases, infection, or trauma. Improved treatments with chemotherapy, radiation, and biologics are increasing survival of patients with malignancies, which has increased the indications for aggressive treatment of these tumors. The dimensions of the amputation vary with oncologic requirements, and nonstandard flaps often are necessary.…

Amputations of the Lower Extremity

Lower limb amputations are the most common of all amputations. Despite advances in revascularization techniques, the most common indication for lower extremity amputation remains a dysvascular limb, including that caused by diabetes mellitus and peripheral vascular disease. Peripheral vascular disease from all causes affects over 8 million Americans. The rate of lower extremity amputation in this population is around 4 per 1000. Amputation of the contralateral…

Amputations of the Foot

As a percent of amputations involving the lower extremity, those around the foot and ankle are becoming increasingly common ( Fig. 15.1 ). With advances in vascular and perfusion assessment and improvements in foot prostheses and footwear, success with ankle and partial foot amputations, as measured by functional, independent living, seems to be improving. When it is determined that limb salvage is not in a patient’s…

General Principles of Amputations

Amputation is the most ancient of surgical procedures. Advancements in surgical technique and prosthetic design historically were stimulated by the aftermath of war. Early surgical amputation was a crude procedure by which a limb was rapidly severed from an unanesthetized patient. The open stump was crushed or dipped in boiling oil to obtain hemostasis. The procedure was associated with high complication and mortality rates due to…

Salvage Operations for the Shoulder and Elbow

This chapter discusses the indications and techniques for arthrodesis of the shoulder and elbow joints as well as the most common tendon transfers performed around the shoulder. Because of the limited function and morbidity after shoulder and elbow arthrodesis, as well as the development of more reliable alternatives, the indications for arthrodesis are becoming increasingly rare. Unlike arthrodesis, tendon transfers around the shoulder continue to be…

Shoulder and Elbow Arthroplasty

Reconstructive Procedures of the Shoulder Prosthetic replacement of the glenohumeral joint has become accepted as a successful treatment for a variety of degenerative, traumatic, and posttraumatic conditions around the shoulder. Multiple studies with long-term follow-up have demonstrated improvements in pain and function with excellent longevity. As experience with primary arthroplasty has accumulated, improved techniques for revision surgery have evolved as well. In the past 2 decades,…

Ankle Arthrodesis

Ankle arthritis is a physically disabling condition, and its treatment can be both challenging and rewarding for the patient and the treating physician. Gait derangement is common in patients with ankle arthritis, and associated pain in the knee, hip, or back often contributes to general health problems. Arthrodesis, although not always perfect in outcome, can obtain a stable, pain-free ankle and dramatic improvement in the function…

Total Ankle Arthroplasty

Although many orthopaedic surgeons abandoned ankle arthroplasty because of high failure and complication rates, the continued search for alternatives to ankle arthrodesis for ankle arthritis has led to a renewal of interest. The development of contemporary designs more biomechanically compatible with the anatomy and kinematics of the ankle, improved techniques and instrumentation, and the introduction of biologic ingrowth for component fixation have led to a profusion…

Soft-Tissue Procedures and Osteotomies About the Knee

This chapter discusses the surgical treatment of nontraumatic abnormalities involving the bone, muscles, tendons, tendon sheaths, fascia, and bursae of the knee. The cause of these disorders may be degenerative, developmental, related to repetitive use, or a combination of these factors. Many of these disorders are encountered frequently in office practice, but few require surgery. Most respond favorably to treatment such as rest, application of ice…

Arthrodesis of the Knee

Indications and Results With the success of total knee arthroplasty, knee arthrodesis seldom is performed as a primary operation and usually is reserved for those few patients who are not candidates for total knee replacement. Occasionally, arthrodesis may be more appropriate than arthroplasty in a young patient with severe arthrosis because of the patient’s weight, occupation, or activity level. Other possible indications for primary arthrodesis include…

Arthroplasty of the Knee

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 total knee arthroplasty (TKA) era ( Fig. 7.1 ). This prosthesis design allowed mechanical considerations to outweigh the desire to reproduce anatomically the kinematics of normal knee motion. Influenced largely by the previous Imperial College/London Hospital design,…

Hip Pain in the Young Adult and Hip Preservation Surgery

It has long been known that significant hip deformity resulting from childhood conditions such as developmental dysplasia of the hip and Legg-Calvé-Perthes disease can lead to secondary hip osteoarthritis in adult life. Over the past two decades, more subtle deformity of the hip has been implicated in the development of osteoarthritis in patients who previously were thought to have “primary osteoarthritis” of the hip. Primary or…

Arthrodesis of the Hip

Arthrodesis of the hip is an infrequently performed procedure with few indications. Advances in total hip arthroplasty, which have greatly improved functional scores and patient satisfaction, have made hip fusion a much less desirable option for most patients. Good intermediate outcomes have been reported after total hip arthroplasty in patients as young as adolescence. Nevertheless, a number of recent literature reviews agree that hip arthrodesis still…

Surface Replacement Hip Arthroplasty

Currently, younger patients make up the fastest growing group of total hip arthroplasty (THA) patients; however, American Academy of Hip and Knee Surgeons (AAHKS) surveys have demonstrated that younger patients report decreased satisfaction and less frequent return to high-level activities than older THA patients. Surface replacement arthroplasty (SRA) is a potential treatment option for this group of younger, high-demand, hip arthroplasty patients. Hip resurfacing is not…

Arthroplasty of the Hip

Total hip arthroplasty is the most commonly performed adult reconstructive hip procedure. This chapter discusses cemented and noncemented arthroplasties, bearing choices, and current trends in surgical approaches and less invasive techniques. In addition, revision hip arthroplasty, which comprises an enlarging segment of procedures performed, is reviewed. The results of the Charnley total hip arthroplasty (THA) are the benchmark for evaluating the performance of other arthroplasties. The…

Advanced Imaging in Orthopaedics

Although routine radiography currently remains the primary imaging modality in orthopaedics, more advanced imaging techniques are now an integral part of the modern orthopaedic practice. Modalities such as magnetic resonance imaging (MRI), computed tomography (CT), and ultrasonography (US) are valuable diagnostic tools and are fundamental components of image-guided interventional procedures. The scope of these advanced imaging techniques across the field of orthopaedics is far too broad…

Surgical Techniques

Surgical Techniques There are several surgical techniques especially important in orthopaedics: use of tourniquets, use of radiographs and image intensifiers in the operating room, positioning of the patient, local preparation of the patient, and draping of the appropriate part or parts. Operative techniques common to many procedures, fixation of tendons or fascia to bone, and bone grafting also are described. Tourniquets Operations on the extremities are…