1 Chapter 30 Orthopedic Surgery. 2 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. Orthopedic Surgery Review.

1

Chapter 30Chapter 30

Orthopedic SurgeryOrthopedic Surgery

2 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Review terms and definitions listed at beginning of chapter

Use your medical dictionary if necessary

3 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bone tissue Cortical (compact) found on the surface of bones Cancellous (spongy) found on the end of bones

and the inner layer

4 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Flat bone, showing compant and cancellous layers, haversian system, and trabeculae

(From Thibodeau GA, Patton KT: Anatomy and physiology, ed 6, St Louis, 2007, Mobsy)

5 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bone tissue and membranes (cont.)• The medullary canal

Red marrow– Found in the small spaces of

the cancellous bone– Highly vascular

Yellow marrow– Consists mainly of fat cells

and connective tissue– Found in the medullary cavity

of long bones

6 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Anatomy of a long bone.

(From Thibodeau G, Patton K: Anatomy and physiology, ed 6, St. Louis, Mosby, 2007.)

7 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bone membrane Endosteum

• Lines the inner channels of long bones and fills the interstitial spaces of cancellous bone and the Haversian canals

• It initiates bone growth and provides nutritional substance to bones

8 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bone landmarks• Crest

• Spine

• Condyle

• Process

• Tubercle

• Tuberosity

• Foramen

• Sinus

• Sulcus

9 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

(From Thibodeau GA, Patton KT: Anatomy and physiology, ed 6, St Louis, 2007, Mosby.)

The skeleton Anterior view of a

skeleton

10 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

The skeleton (cont.) Posterior view of a

skeleton

(From Thibodeau GA, Patton KT: Anatomy and physiology, ed 6, St Louis, 2007, Mosby.)

11 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bone healing Inflammatory phase Reparative phase Remodeling

12 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Joints Synarthrosis

• Limited movement

Amphiarthrosis• Slight movement

Synovial or diarthrosis• Freely movable

13 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Joints Synovial joint

• Consists of articulating bone ends and connective tissues that surround and bind them

• Surrounding joint is a tough fibrous tissue called the joint capsule

• Joint capsule is lined with a membrane called the synovial membrane

14 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Synovial Joint

(From D Vidic B, Suarez FR: Photographic atlas of the human body, St Louis, Mosby.)

15 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Joints Nonsynovial

• Immovable cartilaginous joint

16 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Anatomical movement Hinge joint Saddle Gliding Ball and socket Pivot Condyloid

17 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Ligaments Ligaments attach bones to each other,

providing flexibility and strength to the skeletal structure

18 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Muscles of the human body in anterior position.

(From Thibodeau GA, Patton KT: Anthony's textbook of anatomy and physiology, ed 17, St Louis, 2003, Mosby.)

19 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Muscles of the human body in posterior position.

(From Thibodeau GA, Patton KT: Anthony's textbook of anatomy and physiology, ed 17, St Louis, 2003, Mosby.)

20 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Diagnostic procedures X-rays Magnetic resonance imaging (MRI) Computed tomography (CT) CT-angiogram Ultrasound

21 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Patient transport and transfer Patients may arrive in traction Patients may have external fixators Patients may have antishock garments May need additional personnel to transfer patient

to operating room (OR) table

22 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Positioning Standard OR table Orthopedic table (fracture table)

• Jointed

• Open design

• Translucent supports

23 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Orthopedic Table

A, Orthopedic table used for procedures of the hip and femur. The open configuration use allows C-arm fluoroscope positioning. The hips may be distracted by adjusting the leg extensions. B, Patient in lateral position.

(From Miller M et al: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders.)

24 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Hemostasis Monitored blood loss Pneumatic tourniquet Hemostatic agents

25 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Infection control Particular attention paid to airborne contaminants

and droplet contamination Laminar airflow rooms with greater than

300 exchanges per minute Use of ultraviolet lights Use of “space suits”

26 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Fractures

Common fracture patterns.(From Thibodeau GA, Patton KT: Anthony's textbook of anatomy and physiology, ed 17, St Louis, 2003, Mosby.)

27 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Fracture classification criteria Name of the bone location Pattern of fracture Level of communution Displacement Pathological origin

28 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Fracture patterns Transverse Oblique Spiral Impacted Comminuted Open fracture Greenstick

29 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Biomechanical forces Torsion or torque Shear force Axial force Energy transfer

30 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Reduction Bringing the bone fragments into anatomical

alignment

Types of reduction Open reduction Closed reduction

31 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Fixation Mechanical or structural method used to hold bone

fragments together

Types of fixation Internal fixation External fixation

32 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Surgical options for fixation Open reduction internal fixation Open reduction external fixation Closed reduction external fixation

33 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Traction

Traction. A, Emergency traction using soft straps and rods. B, Skeletal traction of the femur following surgery to insert traction pins.(A from Wolinsky PR, Johnson KD: Femoral shaft fractures. In Browner BD, Jupiter TB: Levine AM, Trafteon PG [eds]: Skeletal trauma, ed 2, Philadelphia, 1998, WB Saunders; B from Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders.)

34 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Internal fixation devices• Implants are used to stabilize the fracture during bone

healing Surgical steel Titanium Steel alloy Bioabsorbable implants

35 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Immobilization methods• Casts Proper placement of cast brings patient safety issues

– Patient’s limb should be elevated– Webril should be placed so no wrinkles are in cotton to cause

pressure sores– As plaster is placed, assistant must not make marks in plaster

as it dries—these may cause pressure sores – Reflective materials will reflect heat given off by

casting material and may burn patient’s limb– Tip of limb should be cleaned of all prepping solution so patient

may be monitored for signs of circulatory disruption: increasing pain, pain that progresses into numbness, cyanotic skin, cold skin, poor capillary refill

36 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Power equipment Orthopedic drill

and accessories

Orthopedic drill and accessories.A, Electric drill and drill heads. B, Pneumatic low speed drill. C, Jacob's chuck. D, Jacob's chuck keys.(A from Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby; B-D Courtesy of Zimmer, Inc.)

37 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Drill attachments Burr Chuck Depth gauge Drill bit Drill guide Reamer Shaver Tip

38 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Orthopedic instrumentation (cont.) Reamers

(From Tighe S: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby.)

39 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Drill bit.

(From Browner BD, Jupiter JB, Levine AM, et al: Skeletal trauma: Basic science, management and reconstruction, ed 3, Philadelphia, 2003, Saunders.)

40 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Types of saws Reciprocating saw Sagittal saw Oscillating saw

41 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Hand Instruments

Clamps.(Courtesy of Sklar Instruments.)

42 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Measuring devices.

(From Phillips N: Berry and Kohn's operating room technique, ed 11, St. Louis, Mosby, 2007.)

43 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Periosteal elevators top to bottom: Freer, Langenbeck, Key, and Cushing elevators.

(Picture courtesy of the College of Southern Idaho, Twin Falls, Idaho.)

44 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Rongeurs

A, Stille-Liston rongeur. C, Stille-Horsley rongeur.(Courtesy of Sklar Instruments.)

45 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Osteotomes and Gouges

D, Lambotte osteotome (often called "lambotte"). E, Smith Peterson gouge.(Courtesy of Sklar Instruments.)

46 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Implants Pins and bolts Nails and rods Staples Plates and screws Screws

47 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Implants (cont.) Sequential steps to orthopedic

screw placement:

1. Drill a hole

2. Measure with a depth gauge

3. Tap

4. Place the screw

48 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Implants, continued Orthopedic implants

• Documentation should include The patient’s permanent record The operative report The implant registry The manufacturer

49 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Implant log Facility name and address Manufacturer's identification information Serial number, lot number, other information Patient identification Surgeon identification

50 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Implant sterilization Prepackaged items come sterilized Plates, screws, pins and rods come in trays Joint and other specialty implants are sterilized

and packaged by a manufacturer

51 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Implant sterilization Implants must not be flash-sterilized except in

extreme emergencies, and then they should be accompanied by a biological indicator

52 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Screws Head Shaft Threads Tip

53 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Types of screws Cancellous Cortical Lag Herbert Cannulated Self-tapping

54 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Plates Locking plate Static or neutralization plate Reconstruction plate Dynamic compression plate (DCP) Tension band plate Buttressing

55 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Intertrochanteric nail and plate

Intramedullary nail or rod

Wires and cables

Kirschner (K-wire) and Steinman pins

56 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Joint replacement implants Metals

Cobalt-chromium-molybdenum Titanium-aluminum-vanadium Pure titanium Tantalum

Polyethyelen Ceramic

57 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Surface texture Rough ended Beaded Altered surfaces

Design Modular Nonmodular

58 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Graft Autograft

• A segment of one’s own bone

Allograft • Cadaver bone

59 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bone graft substitutes Ceramic

• Composites of calcium phosphate, calcium sulfate, bioactive glass

Polymer• Cross-linked collagen or hydroxyapatite

60 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Graft supplied in the following forms Injectable paste Block form Granules Putty Chips

61 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bone cement Polymethyl methacrylate (PMMA) Used to secure and cement orthopedic implants

• Total knee

• Total hip

• Total shoulder

62 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bone cement risk Occupational

• Vapors released

Patient • Toxicity and vascular events

63 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bone cement safety Two components that are combined and mixed

in a closed container specially designed for use with PMMA

64 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Casting Types of casts: Short arm cast. Long arm cast. Plaster body jacket cast. One and one-half hip spica cast.

65 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Traction

A. Emergency traction using soft straps and rods. B. Skeletal traction of the femur after surgery to insert traction pins. A from Wolinsky PR, Johnson KD: Femoral shaft procedures. In Browner BD, Jupiter TB, Levine AM, Trafteon PG, editors: Skeletal trauma, ed 2, Philadelphia, 1998, WB Saunders; B from Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, WB Saunders

66 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Types of traction Skin traction

• Bucks traction

Skeletal traction • Modular rod and pin fixation

67 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Arthroscopic surgery Review Chapter 20 on minimally invasive surgery Instruments

• Similar to those used on open procedures

Joint distension• Completed with continuous irrigation of saline or

lactated Ringer’s solution

68 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bankart Repair The glenoid rim is reattached to the joint capsule

with a biosynthetic or other anchoring device or with heavy sutures.

69 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Open rotator cuff repair• Goal is to repair disruption in rotator cuff

Reduces pain and shoulder dysfunction

• Shoulder is designed with almost limitless range of motion

Price of such mobility is instability Rotator cuff and deltoid each provide about 50% of

power needed for overhead lifting and 90% of power needed for external rotation

70 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Proximal Plating of the Humerus

A. Several 2-mm Kirschner wires (K-wires) are inserted through the humerus to hold the fragments in place. B. The plate is positioned with one or two K-wires inserted through the screw holes. C. With the K-wires still in place, a drill guide is positioned to align drill holes for screws (Courtesy Zimmer, Warsaw, Ind.)

71 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Proximal Plating of the Humerus (cont.)

D. Drill holes are made with a 3-mm drill bit. The length of the hole is measured with a calibrated depth gauge. E. Bicortical screws are inserted into the proximal and distal ends of the plate. F. Completed repair. (Courtesy Zimmer, Warsaw, Ind.)

72 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Arthroscopic procedures Shoulder arthroscopy

Posterior view for procedure of the glenohumeral joint and subacromial space. (From Miller MD, Chhabra AB, Hurwitz SR, Mihalko WM: Orthopaedic surgical approaches, Philadelphia, 2008, WB Saunders.)

73 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Elbow Arthroplasty

A. Areas of worn cartilage. B. Implant design. (Courtesy Zimmer, Warsaw, Ind.)

74 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Anatomy of the hand.

From Snell RS, Smith MS: Clinical anatomy for emergency medicine, St Louis, 1993, Mosby

75 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Hand procedures Specialized combination of

• Orthopedics

• Vascular

• Neurosurgery

• Plastics and reconstruction

76 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Hand surgery anesthetics General Regional Local anesthesia

77 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Open reduction and internal fixation of the wrist Application of screws, plates, and pins for internal

fixation of the wrist bones

78 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Carpal tunnel release (CTR) Freeing of an entrapped median volar nerve to

restore function to the wrist Can be completed

• Open

• Endoscopically

79 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Metacarpophalangeal joint (MPJ) arthroplasty

A. A V-shaped incision is made. B. The flexor tendon is reattached. C. The collateral ligaments are released. D. The articular surface is exposed. E. The medullary canal is exposed. F. Trial implants and the permanent implant are inserted. G. The ligaments are reconstructed.(From Canale S, Beaty J: Campbell’s operative orthopaedics, ed 11, St Louis, 2007, Mosby)

80 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Dupuytren’s contracture release Common condition in which the fascia of the palm

or fingers contracts Constricted palmar fascia is incised and released

to restore mobility to the hand and fingers.

81 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Repair of intertrochanteric fracture A combination of femoral plate and compression

lag screw used to stabilize a fracture of the femoral neck or proximal femur

82 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Dynamic compression sliding hip screw.

Functional loading of a sliding hip screw causes dynamic compression at the fracture site.

With functional loading, the screw slides through the barrel of the side plate, allowing the fracture to impact or compress.

Note the placement of the cannulated screw in the inferior third of the femoral neck.

(From Browner BD, Jupiter JB, Levine AM, et al: Skeletal trauma: Basic science, management, and reconstruction, ed 3, Philadelphia, 2003, Saunders.)

83 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Intramedullary femoral nailing Repair of a femoral shaft fracture using

intramedullary femoral nails A rigid rod seated in the medullary canal held in

position by locking screws

84 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Hip arthroplasty Remove diseased components of the hip and

replace them with prosthetic devices that restore function for the patient

85 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Reasons for hip arthroplasty Osteoarthritis Osteonecrosis Acetabular fracture Avascular necrosis

86 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Components of a hip arthroplasty Femoral

• Stem

• Neck

• head

Acetabular• Shell

• liner

87 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Fracture of the pelvis Completed for stabilization of the pelvis Completed as an open procedure for reduction

and repair

88 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Knee arthroscopy Completed to diagnose knee pain and joint

discomfort Completed to repair knee and restore normal

function

89 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Knee arthroscopy Menisectomy Anterior cruciate ligament (ACL) repair

90 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Arthroscopic procedures Arthroscopic anterior cruciate ligament (ACL) repair

A. Removal of the graft from the tibial tuberosity B. Sutures may be placed at each end of the graft. C. The pilot holes are positioned to accommodate the graft D. The graft is secured with biosynthentic screws (From Canale S, Beaty J: Campbell’s operative orthopedics, ed 11, St Louis, 2007, Mosby)

91 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Knee arthroplasty Removal of diseased components of the knee

replaced with prosthesis to restore function of the knee

92 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Knee arthroplasty components Femoral component Tibial base plate Polyethylene tibial insert Patella component

93 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Intramedullary nailing (tibia) Placement of a solid rod into the medullary space

of the tibia for repair of a comminuted fracture

94 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Achilles tendon repair Tendon may be torn or ruptured during active

sports such as tennis and basketball. A low level injury could occur while cycling Goal is to return strength and flexibility to

the foot

95 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Percutaneous repair of the Achilles tendon

• Incision smaller

• Scar formation smaller

• Tendon sheath holds clot that is formed, facilitating healing

• No general anesthetic given

• Accelerated rehabilitation possible, with full return to sports

96 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Triple arthrodesis Surgical goal is to reduce pain of unstable ankle

resulting from rheumatoid arthritis Uses fusion to prevent full range of motion

by ankle• After procedure, movement of foot and ankle

are limited to plantar flexion and dorsal flexion

97 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Ankle fracture Open reduction and internal fixation is performed

to stabilize fractures of the distal tibia, the talus, and the calcaneus

Completed using • Cannulated screws

• Pins

• Wire

• Plates

98 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Bunionectomy The goal is to alleviate pain and increase

patient mobility An enlarged metatarsal head is reduced or

removed

99 Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc.

Orthopedic Surgery

Hammertoe Correction

Hammertoe repair.(From Herring JA: Tachdjian's pediatric orthopaedics from the Texas Scottish Rite Hospital for Children, ed 3, Philadelphia, 2002, Saunders.)