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JBJS: Journal of Bone and Joint Surgery
Contents: September 1 2005, Volume 87, Supplement 1, Part 2
Surgical Techniques:
Frank R. Noyes, Sue D. Barber-Westin, and Marc Rankin
Meniscal Transplantation in Symptomatic Patients Less Than Fifty Years
Old
J Bone Joint Surg Am. 2005;87(Supp 1):149-165.
Peter J. Stern, Steven S. Agabegi, Thomas R. Kiefhaber, and Michael L. DiDonna
Proximal Row Carpectomy
J Bone Joint Surg Am. 2005;87(Supp 1):166-174.
R. Stephen J. Burnett, Richard A. Berger, Craig J. Della Valle, Scott M. Sporer,
Joshua J. Jacobs, Wayne G. Paprosky, and Aaron G. Rosenberg
Extensor Mechanism Allograft Reconstruction After Total Knee
Arthroplasty
J Bone Joint Surg Am. 2005;87(Supp 1):175-194.
David Ring, Karl Prommersberger, and Jesse B. Jupiter
Combined Dorsal and Volar Plate Fixation of Complex Fractures of the
Distal Part of the Radius
J Bone Joint Surg Am. 2005;87(Supp 1):195-212.
Hiroshi Ito, Takeo Matsuno, and Akio Minami
Chiari Pelvic Osteotomy for Advanced Osteoarthritis in Patients with Hip
Dysplasia
J Bone Joint Surg Am. 2005;87(Supp 1):213-225.
D. Luis Muscolo, Miguel A. Ayerza, Luis A. Aponte-Tinao, and Maximiliano
Ranalletta
Partial Epiphyseal Preservation and Intercalary Allograft Reconstruction in
High-Grade Metaphyseal Osteosarcoma of the Knee
J Bone Joint Surg Am. 2005;87(Supp 1):226-236.
Marco Innocenti, Luca Delcroix, Marco Manfrini, Massimo Ceruso, and Rodolfo
Capanna
Vascularized Proximal Fibular Epiphyseal Transfer for Distal Radial
Reconstruction
J Bone Joint Surg Am. 2005;87(Supp 1):237-246.
Young-Bok Jung, Ho-Joong Jung, Suk-Kee Tae, Yong-Seuk Lee, and Kee-Hyun Lee
Reconstruction of the Posterior Cruciate Ligament with a Mid-Third
Patellar Tendon Graft with Use of a Modified Tibial Inlay Method
J Bone Joint Surg Am. 2005;87(Supp 1):247-263.
Charles L. Nelson, Jane Kim, and Paul A. Lotke
Stiffness After Total Knee Arthroplasty
J Bone Joint Surg Am. 2005;87(Supp 1):264-270.
Amar S. Ranawat, Chitranjan S. Ranawat, Mark Elkus, Vijay J. Rasquinha, Roberto
Rossi, and Sushrut Babhulkar
Total Knee Arthroplasty for Severe Valgus Deformity
J Bone Joint Surg Am. 2005;87(Supp 1):271-284.
F. Teboul, P. Bizot, R. Kakkar, and L. Sedel
Surgical Management of Trapezius Palsy
J Bone Joint Surg Am. 2005;87(Supp 1):285-291.
Yoshiharu Kawaguchi, Masahiko Kanamori, Hirokazu Ishihara, Tasuku Kikkawa,
Hisao Matsui, Haruo Tsuji, and Tomoatsu Kimura
Clinical and Radiographic Results of Expansive Lumbar Laminoplasty in
Patients with Spinal Stenosis
J Bone Joint Surg Am. 2005;87(Supp 1):292-299.
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Meniscal Transplantation in Symptomatic Patients Less Than Fifty
Years Old
Frank R. Noyes, Sue D. Barber-Westin and Marc Rankin
J Bone Joint Surg Am. 87:149-165, 2005. doi:10.2106/JBJS.E.00347
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COPYRIGHT © 2005
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Meniscal Transplantation
in Symptomatic Patients
Less Than Fifty Years Old
Surgical Technique
By Frank R. Noyes, MD, Sue D. Barber-Westin, BS, and Marc Rankin, MD
Investigation performed at Cincinnati Sportsmedicine and Orthopaedic Center, Cincinnati, Ohio
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A , pp. 1392-1404 , July 2004
INTRODUCTION
Meniscal transplantation remains an evolving area, as investigations
of tissue-processing, secondary sterilization, and long-term function
continue to be performed to evaluate the overall efficacy of the procedure. The primary candidate for the procedure is a young patient who
has had a total meniscectomy and has pain in the tibiofemoral compartment because of early joint arthrosis. There are few treatment options for these patients, and the goal of meniscal transplantation in
the short term is to decrease pain, increase knee function, allow painfree activities of daily living, and delay the progression of tibiofemoral
arthrosis. In this report, we describe the preparation of the meniscal
transplant and the meticulous surgical technique that is required to
achieve an anatomically secure attachment and position in order to
provide load-bearing function in the tibiofemoral joint. There are
differences between the techniques for medial and lateral meniscal
transplantation as a result of the characteristics of the anatomic attachment sites.
SURGICAL TECHNIQUE
Sizing and Inspection
of Meniscal Transplants
Anteroposterior and lateral radiographs are used to measure the approximate width and length of the meniscal transplant1. The surgeon
should have knowledge of the donor-selection criteria and tissueprocessing procedures of the tissue bank as these may vary substantially,
even among tissue banks that are certified by the American Association of Tissue Banks and that follow the guidelines of the United States
Food and Drug Administration. The implications of different processDownloaded from www.ejbjs.org on September 3, 2005
ABSTRACT
BACKGROUND:
The purpose of this study was
to prospectively evaluate the results of meniscal transplantation in a consecutive series of
younger patients treated for
pain in the tibiofemoral compartment following a previous
meniscectomy.
METHODS:
Forty cryopreserved menisci
were implanted into thirty-eight
patients. Sixteen knees also
had an osteochondral autograft
transfer, and nine had a knee
ligament reconstruction. The
clinical outcome and failure rate
of all transplants were evaluated at a mean of forty months
postoperatively. Meniscal allograft characteristics were
determined with use of a rating
system that combined subjective, clinical, and magnetic resonance imaging factors.
continued
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ABSTRACT | continued
RESULTS:
Thirty-four (89%) of the thirtyeight patients rated the knee
condition as improved. Before
surgery, thirty patients (79%)
had pain with daily activities, but
only four (11%) had such pain at
the time of the latest follow-up.
While noteworthy pain was
present in the tibiofemoral compartment in all forty knees before surgery, twenty-seven knees
(68%) had no pain and thirteen
(33%) had only mild compartment pain at the time of the latest follow-up. Twenty-nine
patients (76%) returned to light
low-impact sports without problems. Concomitant osteochondral autograft transfer and knee
ligament reconstruction procedures improved knee function
and did not increase the rate of
complications. Meniscal allograft characteristics were normal in seventeen knees (43%),
altered in twelve (30%), and
failed in eleven (28%).
FIG. 1-A
Site of the posterolateral incision for a lateral meniscal transplant.
CONCLUSIONS:
The short-term results of meniscal transplantation are encouraging in terms of reducing knee
pain and increasing function;
however, long-term transplant
function and any chondroprotective effects remain unknown and
require further investigation.
ing techniques with regard to
graft sterility are important2-4 but
beyond the scope of this report.
We advise the surgeon to
request that the tissue bank provide, well before the surgery, a
photograph of the transplant
that has been selected for each
patient. A metric ruler should be
placed adjacent to the transplant in the photograph to ensure that the allograft is of
adequate size and width. The
surgeon should also be aware
that certain medial menisci have
a hypoplastic anterior horn that
is narrow, inserting distal to the
medial tibial surface (Type III5),
and that these menisci are not
acceptable for implantation.
Also, if the middle one-third of a
medial or lateral meniscus is 8 to
10 mm in width, it is suitable
only for small patients. In addition, if the lateral meniscus has
reduced anteroposterior length,
less than that calculated on the
sagittal radiograph, it is not suitable for implantation.
The meniscus is thawed,
inspected, and prepared prior to
the administration of the anesthesia because it is difficult to
detect implant defects through
the plastic packaging. The implant is also prepared first so
that the surgeon can determine
the depth and width required
for the tibial slot when the cen-
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FIG. 1-B
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FIG. 1-C
Fig. 1-B Incision site in the interval between the posterior edge of the iliotibial band (ITB) and the anterior edge of the biceps tendon.
Fig. 1-C The interval between the lateral head of the gastrocnemius and the posterolateral aspect of the capsule is opened bluntly, just
proximal to the fibular head, without entering the joint capsule proximally.
tral bone-bridge technique is
selected.
Technique for Lateral
Meniscal Transplantation
Preparation
The lateral meniscus, with the
anterior and posterior horns remaining attached centrally to
bone, is a better transplant than
the medial meniscus. Because
the attachment sites and circumference tension relationships are
not disturbed, an arthroscopically assisted tibial slot method2
of attachment can be performed
with a meticulous inside-out
meniscal repair6. The central
bone portion of the transplant
incorporates the anterior and
posterior meniscal attachments
and usually measures 8 to 9 mm
in width, 35 mm in length, and
10 mm in depth. The posterior
8 to 10 mm of bone that protrudes beyond the posterior
horn attachment is removed to
later produce a buttress against
the bone trough in the host
knee. Commercially available
sizing blocks and channel cutters (Stryker Endoscopy, Kala-
mazoo, Michigan, and CryoLife,
Kennesaw, Georgia) allow appropriate sizing.
Surgical Technique
The patient is placed in a supine
position on the operating room
table, with a tourniquet applied
with a leg-holder and the table
adjusted to allow 90° of knee
flexion. The contralateral lower
extremity is placed in a thighhigh elastic stocking and is padded to maintain mild hip flexion
to decrease tension on the femoral nerve. After examination with
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the patient under anesthesia, diagnostic arthroscopy is done to
confirm the preoperative diagnosis and to assess changes in the
articular cartilage. An arthroscopically assisted approach is
used in knees that require a cruciate ligament reconstruction7.
The femoral and tibial tunnels
are drilled, and the ligament
graft is passed through the tunnels, with femoral fixation done
first, followed by the meniscal
transplantation, and then by
tibial fixation of the cruciate
graft. Fixing the ligament graft
at the tibia as the final step allows maximum separation of
the tibiofemoral joint during
meniscal transplantation. It also
prevents failure or problems with
the ligament fixation or ligament graft during the operation.
A limited 3-cm lateral arthrotomy is made just adjacent
to the patellar tendon. Although
there are arthroscopic techniques for preparation of the
tibial slot, we believe that the
limited arthrotomy provides superior visualization and makes
it possible to avoid incision into
the patellar tendon. A second,
3-cm posterolateral accessory
incision is made, centered just
behind the lateral collateral ligament (Fig. 1-A)6,8. The interval
between the biceps tendon insertion and the iliotibial band is
identified and incised (Fig. 1-B).
The lateral head of the gastrocnemius is gently dissected with
Metzenbaum scissors off of the
posterior aspect of the capsule
at the joint line (Fig. 1-C). Care
is taken at this point because dis-
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FIG. 2-A
Figs. 2-A through 2-E Tibial slot technique for lateral and medial meniscal transplantation, which is shown here for the lateral meniscus. An arthroscopically assisted technique or a mini-lateral arthrotomy may be used, but we prefer the mini-arthrotomy as it
offers superior visualization and allows us to avoid incising the patellar tendon. A detailed description of the surgical steps and operative instruments used for the tibial slot
technique is available14. Fig. 2-A A line is established connecting the center of the anterior and posterior horn attachments with an electrocautery device. In the mini-open arthrotomy, a template of the meniscal coronal width is used to verify the medial-to-lateral
width of the transplant so that the slot can be moved appropriately to prevent tibial overhang of the implant.
section that extends too far
proximal to the joint line at
the posterolateral aspect would
enter the joint capsule. If this
occurs, a capsular repair is
required to maintain joint integrity during the inside-out
meniscal repair. The lateral inferior genicular artery is also in
close proximity, and it is identified and preserved. The space
between the posterolateral aspect of the capsule and the lateral head of the gastrocnemius is
further developed bluntly. An
appropriately sized popliteal retractor (Stryker) is placed directly behind the lateral meniscal
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FIG. 2-B
A burr is used to remove the tibial spine and create a
4-mm straight anterior-to-posterior reference slot
along the plane of the tibial slope. This calibrated
guide pin sits flush with the articular cartilage.
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CRITICAL CONCEPTS
INDICATIONS:
The indications for a meniscal allograft procedure are prior meniscectomy, an age of fifty years or
less, pain in the tibiofemoral compartment, no radiographic evidence of advanced arthrosis, and
≥2 mm of tibiofemoral joint space
as seen on 45° weight-bearing
posteroanterior radiographs10.
CONTRAINDICATIONS:
Contraindications include advanced arthrosis of the knee joint
with flattening of the femoral
condyle, concavity of the tibial
plateau, and osteophytes that
prevent anatomic seating of the
meniscal allograft11; axial varus
malalignment in which a weightbearing line of <40% of the medial-lateral transverse width of the
tibial plateau12 is seen on radiographs or valgus malalignment
in which a weight-bearing line of
>60% is seen on radiographs; instability of the knee joint or the
patient’s refusal to undergo concomitant knee ligament reconstruction; knee arthrofibrosis;
muscular atrophy; and previous
joint infection.
FIG. 2-C
The drill guide is used with a guide pin that has been marked with a laser to set the
depth of a second guide pin. This allows a drill to ream 5 mm less to retain the posterior
portion of the tibial slot.
continued
bed. The tourniquet is inflated
only for these two approaches;
otherwise, it is not used.
The width of the transplant
is determined, and an aluminum
foil template of the same width
and length as the transplant is
cut and is inserted into the lateral compartment to determine
the lateralmost margin of the
bone trough. This sizing step is
important to make sure that
there is no lateral overhang of
the meniscal body produced by
placing the bone trough too far
laterally. A rectangular bone
trough is prepared at the anterior and posterior tibial attachment sites of the lateral meniscus
to match the dimensions of the
prepared lateral meniscal transplant. The sequence of steps to
prepare the lateral tibial slot is illustrated in Figures 2-A through
2-D. The tibial bone slot is 1 to 2
mm wider than the transplant,
to facilitate implantation. The
anterior and posterior horns of
the implant are placed into their
normal attachment locations,
adjacent to the anterior cruciate
ligament. The allograft is inserted into the trough (Fig. 2-E),
and the bone portion of the graft
is seated against the posterior
bone buttress to achieve correct
anterior-to-posterior placement
of the attachment sites. A vertical suture in the posterior part
of the meniscal body is passed
posteriorly to provide tension
and facilitate implant placement.
The knee is flexed, extended, and
rotated to confirm correct allograft placement. The posterior
suture is tied, and sutures are
placed in a vertical fashion into
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FIG. 2-D
An 8-mm drill bit with a collar at the defined depth is
used, followed by use of a box cutter to create a rectangular slot of the desired depth and width.
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the anterior one-third of the
meniscus, attaching it to the prepared meniscal rim under direct
visualization.
An alternative technique
is to use a starter chisel and finishing chisels to fashion the tibial trough to its final depth and
width (Fig. 3-A). A tibial trough
sizing guide is employed to check
the length and depth (Fig. 3-B).
The allograft sizing block (Fig.
3-C) confirms that the allograft
bone bridge is of the correct
width and depth.
Two methods are available
for fixation of the central bone attachment. Two 2-0 nonabsorbable sutures (Ticron [Davis and
Geck, Wayne, New Jersey] or
Ethibond [Ethicon, Somerville,
New Jersey]) may be placed in the
central region, brought through a
drill hole, and tied. Our preferred
method involves placement of an
interference screw (7 × 25 mm),
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made of an absorbable composite
material, medial and adjacent
to the central bone attachment9.
The arthrotomy is closed, and
the inside-out meniscal repair
is performed with multiple vertical divergent sutures, which are
placed first superiorly to reduce
the meniscus (Fig. 4) and then
inferiorly in the outer one-third
of the implant. Sutures are not
placed in the middle and inner
thirds of the meniscus to avoid
weakening the implant, which
has a limited healing capability
in these regions (Fig. 5).
Technique for Medial
Meniscal Transplantation
Preparation
The medial meniscal transplant
is inspected to confirm that the
size is appropriate and no degenerative changes are present. The
implant is not prepared until it
is decided whether the central
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bone-bridge technique (which
is preferred) or the two-tunnel
technique (involving separate
anterior and posterior bone
attachments and tunnels) is
required.
The patient is placed in a
supine position on the operating
room table, with a tourniquet
applied with a leg-holder and
the table adjusted to allow 90°
of knee flexion. The contralateral lower extremity is placed in
a thigh-high elastic stocking and
is padded to maintain mild hip
flexion to decrease tension on the
femoral nerve. After examination
with the patient under anesthesia, diagnostic arthroscopy is
done to confirm the preoperative diagnosis and assess changes
in the articular cartilage.
A 4-cm skin incision is made
on the anterior aspect of the tibia
adjacent to the tibial tubercle and
the patellar tendon. A second,
FIG. 2-E
The lateral meniscal implant with the central bone bridge is ready to be placed into the tibial slot.
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FIG. 3-A
Figs. 3-A, 3-B, and 3-C An alternative to the tibial
slot technique. A detailed description of the surgical steps and operative instruments is available15.
Fig. 3-A A starter chisel and finishing chisels are
used to fashion the tibial trough to its final depth
and width.
FIG. 3-B
A tibial trough sizing guide is used to check the length and depth.
FIG. 3-C
The allograft sizing block confirms that the allograft bone bridge
is of the desired width and depth.
3-cm vertical posteromedial incision, similar to that described for
inside-out meniscal repairs8, is
made just posterior to the superficial medial collateral ligament
(Fig. 6-A). The fascia is incised
anterior to the sartorius (Fig. 6-B),
and the pes anserinus muscle
group is retracted posteriorly.
The interval between the semi-
membranosus tendon and the
capsule is sharply dissected. The
layer between the medial aspect
of the gastrocnemius tendon and
the posteromedial aspect of the
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CRITICAL CONCEPTS | continued
PITFALLS:
• The patient is informed that the
transplant is inspected just before the surgical procedure in
the operating room and that the
decision to proceed with the
procedure will be made at this
time if the graft is deemed suitable. Also, there is the remote possibilty that, during
the operative procedure, either the final preparation or the
implantation of the meniscal allograft may not be possible as
a result of problems with its
size or the ability to obtain correct positioning in the joint.
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capsule is separated with blunt
dissection (Fig. 6-C). Great care
is taken to identify and avoid injury to the infrapatellar branches
of the saphenous nerve. The two
approaches are performed with
the tourniquet inflated to 275
mm Hg and usually require fifteen minutes; otherwise, the
tourniquet is not used.
A medial meniscal transplant, with anatomically placed
anterior and posterior bone at-
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tachments, must be appropriately secured to maintain the
desired position in the knee joint
postoperatively and to provide
the circumferential tension required for transplant function. A
template of the medial meniscal
transplant, made of aluminum
foil and measured according
to its anterior-posterior and
medial-lateral dimensions, is
inserted through the limited anterior arthrotomy incision and is
• The preparation of the meniscal
template is critical for successful placement of the final tibial
slot and correct positioning of
the transplant. The aluminum
foil template is made to represent the size of the implant and
is inserted through the limited
anterior arthrotomy incision.
• The slot placement for the
latera or medial meniscal transplant must be exact. Otherwise,
the meniscus may be displaced
at its midportion outside the
joint, or it may be positioned
too far inside the joint and
subsequently incur excessive
compression and tearing. It
is possible to realign the bone
trough a few millimeters medially or laterally in the coronal
plane, and an absorbable interference screw can be used for
fixation in the final coronal adjustment of the implant.
• During medial meniscal transplantation, the template may indicate that the transplant is
excessively wide in the medialto-lateral direction. If it does,
the middle one-third of the
continued
FIG. 4
Cross section showing a popliteal retractor between the lateral head of the gastrocnemius and the posterior aspect of the capsule. A single cannula is introduced from the
adjacent portal to facilitate placement of the vertical sutures into the periphery of the
meniscal implant. LCL = lateral collateral ligament, and PT = popliteus tendon.
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sized to the medial tibial plateau.
This allows the surgeon to mark
the position of the central bone
trough and to determine whether
the meniscal implant will be
properly positioned just adjacent to the tibial attachment of
the anterior cruciate ligament,
without excessive medial tibial
overhang. Next, it is verified that
the anterior and posterior attachments are located at the anatomically correct sites. With the
central bone-bridge technique,
4 to 6 mm of the medial tibial
eminence is removed. If the implant is suitable and there is no
medial tibial overhang, then the
central bone-bridge technique
may be used. If the implant needs
to be adjusted to fit to the me-
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dial tibial plateau by moving the
anterior horn farther laterally,
then the two-tunnel technique
is selected. Once the technique
has been chosen, the meniscal
allograft is prepared.
Central Bone-Bridge Technique
The central bone-bridge technique for medial meniscal transplantation is the same as that
described for lateral meniscal
transplantation. A reference slot is
first created on the tibial plateau
in the anteroposterior direction.
A guide pin is positioned in the
slot, inferiorly on the tibia, and
a cannulated drill bit is placed
over the pin to drill a tunnel.
The final tibial slot is 8 to 9 mm
in width and 10 mm in depth. A
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CRITICAL CONCEPTS | continued
transplant would rest outside of
the medial tibial plateau in order to avoid compromising the
attachment of the anterior cruciate ligament. The two-tunnel
technique is selected to obtain
correct anatomic positioning
and the desired subsequent circumferential hoop stress.
• The use of multiple vertical divergent sutures is required to
position the transplant in the
anatomically correct manner.
There are usually wavy areas in
the implant, with loss of circumferential tension, that are successfully removed by correct
placement of these sutures.
• We prefer the inside-out meniscal repair technique, which
is considered to be the most
precise suturing method.
• We avoid meniscal fixators, with
which it is not possible to provide the same secure fit and exact placement of the implant.
• The sutures should not be
placed in the middle and inner
thirds of the meniscus, as this
could weaken the implant.
• The suturing of the implant is
meticulous, as twelve to fifteen
sutures are required both superiorly and inferiorly, all placed in
a vertical direction. Horizontal
sutures have poor holding ability
and are therefore not used during meniscal transplantation.
• Care is taken not to damage the
articular cartilage. The technique
requires two surgical assistants, one dedicated to holding
the lower limb to open the medial or lateral tibiofemoral compartment for visualization of the
implant and the other seated to
retrieve and tie the sutures at
the posterior aspect of the joint.
FIG. 5
Lateral meniscal graft in place and sutured.
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CRITICAL CONCEPTS | continued
• The suturing of the medial or
lateral posterior horn adjacent
to the posterior attachment requires angulation of the suture needle away from the
neurovascular structures.
• In order for the meniscal transplant to function, it must be
placed at the normal anatomic
insertion sites. If the posterior
horn attachment of the medial
or lateral meniscus is placed
too far posteriorly, it will not
provide proper load-sharing13.
Alternatively, a too anterior position of a medial meniscal
transplant will produce excessive compressive forces and
damage the meniscus.
• We disagree with those who
have advocated techniques of
medial meniscal transplantation in which the posterior bone
portion of a medial meniscal
implant is not retained and the
fibrocartilaginous posterior
horn is placed in a posterior tibial attachment tunnel. Although
such transplants are far easier
to prepare and implant surgically, there are inadequate scientific data to support the
belief that the soft-tissue ends
of the meniscal implant (without the bone attachment) will
heal and provide the circumferential tension in the meniscus
that is required for function.
FIG. 6-A
Figs. 6-A, 6-B, and 6-C The accessory posteromedial approach for a medial meniscal allograft procedure. Fig. 6-A Site of the posteromedial skin incision.
continued
rasp is used to smooth the slot to
allow insertion of the central bone
bridge of the allograft.
The central bone bridge of
the allograft is sized to a width of
7 mm (1 mm less than the dimension at the tibial site) and a
depth of 10 mm9. This allows the
position of the central bone
bridge to be adjusted in the anterior-posterior direction while the
meniscus is positioned to fit in
the anatomically correct position relative to the femoral
condyle.
A vertical suture is placed
through the junction of the
posterior and middle thirds of
the meniscus. A single-barrel
cannula is used to advance the
suture through the capsule at
the corresponding attachment
site of the meniscus, and the suture exits through an accessory
incision (Fig. 7). The meniscus
is passed through the arthrotomy incision into the knee,
with tension placed on the sutures to facilitate proper positioning in the knee joint. Care is
taken to align the bone bridge
with the recipient tibial slot.
The knee is taken through flexion and extension and tibial rotation to align the implant.
Once the appropriate anteriorposterior position of the central bone bridge is achieved, a
guide wire is inserted between
the bone bridge and the lateral
side of the slot. A tap is inserted
over the guide wire to create a
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FIG. 6-C
Fig. 6-B The incision is shown through the anterior portion of the sartorius fascia. Fig. 6-C The interval is opened between the posteromedial aspect of the capsule and the gastrocnemius tendon, just proximal to the semimembranosus tendon (arrow). The fascia over the tendon is excised to its tibial attachment to facilitate retrieval of the meniscal sutures.
path for an interference screw
with the bone bridge held in
place manually. An absorbable
bone interference screw is inserted adjacent to the bone
bridge.
The joint is again taken
through a full range of motion,
and the position of the implant
is verified. Occasionally, there is
an osteophyte on the anterior
aspect of the medial tibial plateau, and this must be resected
to avoid compression of the
meniscal implant. The central
bone bridge of the implant is
fixed with an interference screw
(7 × 25 mm). The meniscus is
sutured with vertical divergent
sutures (2-0 Ethibond) under
direct visualization. The anterior arthrotomy is closed, and
the inside-out vertical divergent
sutures are placed, as described,
to sew the meniscus to the meniscal bed, with removal of
any implant undulations and
restoration of circumferential
meniscal tension. The central
bone bridge of the implant
provides fixation of the anterior
and posterior portions of the
implant and healing into the
host tibia (Fig. 8).
Two-Tunnel Technique
If it is determined that the central bone-bridge technique is not
acceptable, the surgeon must
prepare separate anterior and
posterior bone portions of the
meniscal transplant. Both are secured to anatomic attachment
sites to provide a functional
meniscal implant (Fig. 9). The
transplant is prepared with a
posterior bone plug, 8 mm in
diameter and 12 mm in length,
and an anterior bone plug, 12
mm in diameter and 12 mm in
length. Two 2-0 nonabsorbable
Ethibond sutures are passed ret-
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CRITICAL CONCEPTS | continued
AUTHOR UPDATE:
In our original study, we used the
central bone-bridge technique,
which maintains a central bone
bridge between the anterior and
posterior meniscal attachments,
primarily for lateral meniscal
transplantation. This is also now
our preferred technique for medial meniscal transplantation, as
described in this article.
Currently, we use a template of
the meniscal implant to determine the location of the bone
slot. The lateralmost placement
of the central bone slot for the
medial meniscal implant is limited by the tibial attachment of
the anterior cruciate ligament.
The anterior horn of the medial
meniscus must not be of a TypeIII configuration5⎯i.e., it must
not insert too far distally on the
anterior tibial margin. If assessment of the medial meniscal
transplant reveals a medial-tolateral size mismatch, then separate anterior and posterior
bone attachments and tunnels
are required. The posterior part
of the bone-meniscus transplant is placed at the normal attachment, and the anterior horn
is placed in a medial-to-lateral
direction to restore correct tensioning and position in the joint.
FIG. 7
Cross section showing the arthroscope, needle cannula, and popliteal retractor in
place. The meniscus is passed through the arthrotomy incision into the knee with tension placed on the sutures to facilitate proper positioning in the knee joint. With use of
a single-barrel cannula, the suture is advanced through the capsule at the corresponding attachment site of the meniscus and exits through an accessory incision.
continued
rograde through each bone plug,
with two additional locking sutures placed in the meniscus adjacent to the bone attachment
for subsequent secure fixation
of the bone plugs within the tibial tunnel.
A guide pin is placed adjacent to the tibial tubercle and is
directed to the anatomic posterior
meniscal attachment. A tibial tunnel is drilled over the guide wire
to a diameter of 8 mm. The bonetunnel edges are chamfered. A
limited notchplasty of the medial
femoral condyle is usually required. At least 8 mm of opening
adjacent to the posterior cruciate
ligament in the femoral notch is
needed to pass the posterior osseous portion of the graft. On occasion, a subperiosteal release of
the long fibers of the tibial attach-
ment of the medial collateral ligament (with later suture-anchor
repair) is required to open the
medial part of the tibiofemoral
joint sufficiently. The meniscal
bed is prepared by removing any
remaiing meniscal tissue while
preserving a 3-mm rim when
possible. The meniscal bed is
rasped for revascularization of
the graft.
A 3-cm anteromedial arthrotomy is used to pass the pos-
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CRITICAL CONCEPTS | continued
For tight knees with only a few
millimeters of medial joint opening, the central bone-bridge technique enables the surgeon to
avoid performing a partial detachment of the distal part of
the medial collateral ligament,
which would otherwise be required to gain access to the joint
for suturing and to avoid damage to the articular cartilage.
There are now newer techniques for tissue-processing and
advanced donor-screening tests
that provide highly safe meniscal
transplants with an exceedingly
low risk of disease transmission.
Advances in tissue-processing
and Food and Drug Administration guidelines for tissue banks
are important to ensure the
safety of allografts.
FIG. 8
Weight-bearing posteroanterior radiograph of a thirty-six-year-old woman, made six years
after medial meniscal transplantation with a central bone-bridge technique, showing incorporation of the bone bridge into the host with preservation of the medial joint space.
terior bone portion of the graft,
with a secondary meniscal body
suture passed out through the incision for the posteromedial approach. The surgeon is seated
with a headlight in place, and the
patient’s knee is flexed to 90°. On
occasion, there are anterior osteophytes on the medial tibial
plateau that require resection.
The posterior attachment guide
wire is retrieved, and the sutures
attached to the posterior bone
are passed. A second suture is
placed into the midportion of the
meniscus and is passed insideout through the incision for the
posteromedial approach to guide
the meniscus.
The knee is flexed to 20°
under a maximum valgus load to
pass the posterior bone portions
of the graft, with the secondary
meniscal body suture held by an
assistant. A nerve hook is used to
gently assist the passage of the
graft. With use of a headlight and
retractors, it is possible to confirm appropriate passage of the
meniscal graft into the medial tibiofemoral compartment. Care is
taken to not advance the posterior part of the meniscal body
into the tibial tunnel but to only
seat the bone portion of the graft
in order to avoid shortening of
the meniscal graft. The posterior
meniscal bone attachment and
the midbody sutures are tied
over the tibial post to provide
tension in the posterior bone attachment and the posterior onethird of the meniscus. The knee
is flexed and extended to assess
meniscal fit and displacement.
The optimal location for the an-
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FIG. 9
Two-tunnel technique for medial meniscal allograft transplantation. The illustration
shows insertion of the transplant, including posteromedial suture placed to facilitate meniscal reduction. The anterior and posterior bone attachments of the medial meniscal
transplant are fixed into separate tibial tunnels.
FIG. 10
Appearance of the final fixation of the medial meniscal transplant in the anterior and
posterior tunnels and vertical divergent sutures.
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terior meniscal bone attachment
at the anteromedial junction of
the tibial plateau is identified,
with the medial-to-lateral placement in the coronal plane determined with the knee in full
extension. A 12-mm rectangular
bone attachment is fashioned to
correspond to the anterior bone
portion of the meniscal graft. A
4-mm bone tunnel is placed at
the base of this bone trough, and
it exits at the anterior aspect of
the tibia just proximal to the posterior bone tunnel. The sutures
are passed through the bone tunnel, and the anterior horn is
seated. Full knee flexion and extension are again performed to
determine proper graft placement and fit. Tension is applied
to the anterior bone sutures,
which are not tied at this point
but are used to maintain tension
in the graft during the inside-out
suture repair. This meticulous
seating of the meniscal transplant
under circumferential tension
with bone attachment of both
the anterior and the posterior
horn is believed to be crucial for
future meniscal weight-bearing
position and function.
The anterior arthrotomy is
closed, and the arthroscope is inserted into the anterolateral portal for the posterior meniscal
repair and into the anteromedial
portal for the repairs of the middle and anterior one-thirds, with
the single needle cannula inserted in the other anterior portal. The meniscal repair is
performed in an inside-out fashion, starting with the posterior
horn, with use of multiple verti-
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cal divergent sutures of 2-0 nonabsorbable Ethibond both
superiorly and inferiorly, with
constant tensioning of the meniscus from posterior to anterior
to establish circumferential tension. The assistant, seated with a
headlight, retrieves the suture
needles through the posteromedial approach. Each suture is
placed and tied, bringing the meniscus directly to the meniscal
bed with observation that meniscal placement, fixation, and tension are correct. The anterior
arthrotomy incision is again
opened, and the final tensioning
and tying of the anterior horn
bone sutures are performed with
use of the anterior tibial post.
Occasionally, additional sutures
are required to secure the most
anterior one-third of the meniscus to the capsular attachments,
which is done under direct vision
(Fig. 10). After final inspection
of the graft with knee flexion and
extension and tibial rotation, the
operative wounds are closed in a
routine fashion.
Frank R. Noyes, MD
Sue D. Barber-Westin, BS
Marc Rankin, MD
Deaconess Hospital, 311 Straight Street, Cincin-
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nati, OH 45219. E-mail address for S.D. BarberWestin: [email protected]
Technical considerations in the management
of complex meniscus tears. Clin Sports Med.
1996;15:511-30.
The authors did not receive grants or outside funding in support of their research or preparation of
this manuscript. They did not receive payments or
other benefits or a commitment or agreement to
provide such benefits from a commercial entity.
No commercial entity paid or directed, or agreed
to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
7. Noyes FR, Barber-Westin SD. A comparison of results in acute and chronic anterior
cruciate ligament ruptures of arthroscopically assisted autogenous patellar tendon
reconstruction. Am J Sports Med. 1997;
25:460-71.
The line drawings in this article are the work of
Joanne Haderer Müller of Haderer & Müller
([email protected]).
doi:10.2106/JBJS.E.00347
REFERENCES
1. Pollard ME, Kang Q, Berg EE. Radiographic sizing for meniscal transplantation.
Arthroscopy. 1995;11:684-7.
2. Cole BJ, Carter TR, Rodeo SA. Allograft
menisca transplantation: background, techniques, and results. J Bone Joint Surg Am.
2002;84:1236-50.
3. Barbour SA, King W. The safe and effective
use of allograft tissue—an update. Am J
Sports Med. 2003;31:791-7.
4. Vangsness CT Jr, Garcia IA, Mills CR, Kainer
MA, Roberts MR, Moore TM. Allograft transplantation in the knee: tissue regulation, procurement, processing, and sterilization. Am J
Sports Med. 2003;31:474-81.
5. Berlet GC, Fowler PJ. The anterior horn
of the medical meniscus. An anatomic study
of its insertion. Am J Sports Med. 1998;
26:540-3.
6. Rubman MH, Noyes FR, Barber-Westin SD.
8. McLaughlin JR, Noyes FR. Arthroscopic
meniscus repair: recommended surgical
techniques for complex meniscal tears.
Tech Orthop. 1993;8:129-36.
9. Farr J, Meneghini RM, Cole BJ. Allograft
interference screw fixation in meniscus
transplantation. Arthroscopy. 2004;20:
322-7.
10. Rosenberg TD, Paulos LE, Parker RD,
Coward DB, Scott SM. The forty-five-degree
posteroanterior flexion weight-bearing radiograph of the knee. J Bone Joint Surg Am.
1988;70:1479-83.
11. Noyes FR, Barber-Westin SD, Butler DL,
Wilkins RM. The role of allografts in repair
and reconstruction of knee joint ligaments
and menisci. Instr Course Lect. 1998;
47:379-96.
12. Dugdale TW, Noyes FR, Styer D. Preoperative planning for high tibial osteotomy. The effect of lateral tibiofemoral separation and
tibiofemoral length. Clin Orthop Relat Res.
1992;274:248-64.
13. Alhalki MM, Hull ML, Howell SM. Contact
mechanics of the medial tibial plateau after
implantation of a medial meniscal allograft. A
human cadaveric study. Am J Sports Med.
2000;28:370-6.
14. Farr J, Cole B. Slot instruments for meniscal transplantation: surgical technique. San
Jose, CA: Stryker Endoscopy; 2004.
15. Halbrecht JL. Meniscal reconstruction
trough surgical technique. Kennesaw, GA:
CryoLife; 2000.
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The PDF of the article you requested follows this cover page.
Proximal Row Carpectomy
Peter J. Stern, Steven S. Agabegi, Thomas R. Kiefhaber and Michael L. DiDonna
J Bone Joint Surg Am. 87:166-174, 2005. doi:10.2106/JBJS.E.00261
This information is current as of September 3, 2005
Reprints and Permissions
Click here to order reprints or request permission to use material from this
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www.jbjs.org
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COPYRIGHT © 2005
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Proximal Row
Carpectomy
Surgical Technique
By Peter J. Stern, MD, Steven S. Agabegi, MD, Thomas R. Kiefhaber, MD, and Michael L. DiDonna, MD
Investigation performed at the University of Cincinnati College of Medicine, Cincinnati, Ohio
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 2359-2365, November 2004
ABSTRACT
BACKGROUND:
Proximal row carpectomy is an
accepted motion-sparing surgical procedure for the treatment
of degenerative conditions of the
wrist. However, there is little information regarding the long-term
clinical and radiographic results
following this procedure.
INTRODUCTION
Proximal row carpectomy is an accepted motion-sparing procedure
for a variety of degenerative conditions of the wrist. Salvage procedures for the wrist can be classified as motion-sparing or motionsacrificing. Total wrist arthrodesis is a motion-sacrificing procedure.
METHODS:
Twenty-two wrists in twenty-one
patients underwent proximal row
carpectomy for the treatment of
degenerative arthritis between
1980 and 1992. Objective and
subjective function was assessed after a minimum duration of
follow-up of ten years (average,
fourteen years).
RESULTS:
There were four failures (18%)
requiring fusion at an average
of seven years. All four failures
occurred in patients who were
thirty-five years of age or less
at the time of the proximal row
carpectomy (p = 0.03). The
wrists that did not fail had an
average flexion-extension arc
FIG. 1
continued
The incision.
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ABSTRACT | continued
FIG. 2
Transposition of the extensor pollicis longus (EPL).
Proximal row carpectomy and
scaphoid excision with fourcorner fusion of the capitate,
lunate, hamate, and triquetrum
are two commonly performed
motion-sparing procedures for
disorders of the proximal carpal
row. The former is preferred in
the absence of degenerative
changes in the capitolunate
joint, whereas the latter is preferred in the presence of such
changes1. Proximal row carpectomy involves excision of the
scaphoid, lunate, and triquetrum, which allows the capitate to settle into and articulate
with the lunate fossa of the dis-
tal part of the radius. The procedure is appealing because of its
technical simplicity, its generally
predictable outcomes, and the
ease of rehabilitation following
its performance. We describe
the procedure in detail.
SURGICAL TECHNIQUE
Anesthesia
Either regional or general anesthesia is used, according to the
discretion of the anesthesiologist
and the patient’s wishes. At our
institution, regional nerve blocks
are commonly administered as
an adjunctive means of providing postoperative analgesia.
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of 72°, associated with an average grip strength of 91% of that
on the contralateral side. The
patients were very satisfied
with fourteen of the eighteen
wrists that did not fail and were
satisfied with the remaining
four. The patients rated nine
wrists as not painful, four as
mildly painful, five as moderately painful, and none as severely painful. The average
Disabilities of the Arm, Shoulder and Hand score was 9
points. Radiographs revealed
no loss of the radiocapitate
space in three of the seventeen
wrists for which radiographs
were made, reduced space in
seven, and complete loss of
the space in seven. With the
numbers available, there was
no significant association between loss of joint space seen
on radiographs and subjective
and objective function.
CONCLUSIONS:
At the time of long-term followup, all patients older than thirtyfive years of age at the time of
a proximal row carpectomy had
maintained a satisfactory range
of motion, grip strength, and
pain relief and were satisfied
with the result. Caution should
be exercised in performing the
procedure in patients younger
than thirty-five years of age.
Although degeneration of the
radiocapitate joint was seen
radiographically in fourteen of
the seventeen wrists, it did not
preclude a successful clinical
result.
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FIG. 3
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FIG. 4
Fig. 3 Exposed carpal bones. ECRB = extensor carpi radialis brevis, and EDC = extensor digitorum communis.
Fig. 4 Excision of the scaphoid. Fig. 5 After the proximal carpal bones have been removed, the capitate articulates with
the lunate fossa of the distal part of the radius.
FIG. 5
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FIG. 6-A
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FIG. 6-B
Figs. 6-A through 6-K Radiographs and photographs of a physician who underwent proximal row carpectomy and was followed for twelve
years. Figs. 6-A and 6-B Anteroposterior and lateral radiographs made after the patient felt a pop while playing tennis, at the age of forty-five
years. The findings on the radiographs appear normal, and a scapholunate disruption was initially unrecognized. No treatment was given.
Positioning
The patient is positioned supine on the operating table with
the affected arm abducted 90°
on a hand table. A tourniquet
placed high on the brachium
is used to achieve a bloodless
field.
Skin Incision
A dorsal longitudinal incision,
7 to 8 cm in length, is placed
just radial to the Lister tubercle
(Fig. 1). Dissection is carried
down to the extensor retinaculum. Cutaneous flaps are elevated radially and ulnarly, with
care taken to protect the sen-
sory branches of the radial and
ulnar nerves.
Carpal Exposure
The extensor pollicis longus tendon is readily identified distal to
the retinaculum as it crosses obliquely over the radial wrist extensors (Fig. 2). The retinaculum
overlying the third dorsal compartment is divided in its entirety
with use of scissors. The extensor pollicis longus is mobilized
by placing a rubber tape around
its tendon, and it is retracted
radially. Just deep to the extensor pollicis longus, the extensor
carpi radialis brevis is identified
as it runs longitudinally to insert
at the base of the third metacarpal. The extensor carpi radialis
brevis tendon is also retracted
radially. The posterior interosseous nerve is identified beneath
the extensor tendons of the
fourth dorsal compartment, and
a 1-cm segment is resected. The
dorsal capsule is longitudinally
incised parallel to the extensor
carpi radialis brevis, with care
taken not to score the hyaline
cartilage on the head of the capitate. Capsular flaps are then reflected radially and ulnarly from
the distal part of the radius. Care
should be taken to stay in the
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FIG. 6-C
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FIG. 6-D
Two years later, scapholunate diastasis and narrowing of the radioscaphoid joint space were noted.
subperiosteal plane and to avoid
entering the dorsal compartments. Distally, the capsule is
elevated from the carpus in a
similar fashion so that the scaphoid, lunate, and triquetrum are
visualized (Fig. 3).
Inspection
The integrity of the articular
surfaces of the head of the capitate and the lunate facet of the
distal part of the radius is then
inspected. If there is loss of cartilage or eburnated bone on either
of those surfaces, a proximal row
carpectomy is contraindicated
and the surgeon should consider
an alternative procedure such
as scaphoid excision with fourcorner arthrodesis or a total wrist
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FIG. 6-E
Intraoperative photograph showing an eburnated proximal pole
of the scaphoid (arrow).
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arthrodesis. If there is any question with respect to proper identification of the carpal bones,
fluoroscopy with a metal probe
should be used for confirmation.
Removal of Carpal Bones
There are many techniques for
removing the scaphoid, lunate,
and triquetrum. We remove
the scaphoid first and start by
sharply dividing the scapholunate interosseous ligament.
Next, a threaded 1/8-in (3.2-mm)
Steinmann pin is inserted into the
scaphoid in a dorsal-proximal
to volar-distal fashion to serve as
a joystick. In addition, small
Homan retractors are placed beneath the distal pole (tuberosity)
of the scaphoid to facilitate re-
FIG. 6-F
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moval of the entire bone (Fig. 4).
With use of sharp dissection with
a #15 blade, the volar capsular
and ligamentous attachments
are reflected from the scaphoid
and the bone is removed in one
piece. Attention is then turned
to the removl of the lunate and
triquetrum. These bones are usually easier to remove than is the
scaphoid. Care must be exercised
not to damage the head of the
capitate or the lunate fossa of the
distal part of the radius. Again, a
threaded Steinmann pin can be
used as a joystick to facilitate removal of these bones.
Some surgeons prefer to
remove the bones piecemeal;
however, we have found that
this takes longer and may risk
JBJS . ORG
CRITICAL CONCEPTS
INDICATIONS:
The articular surfaces of the capitate head and the lunate fossa of
the distal part of the radius must
contain intact articular cartilage.
The indications for the procedure
include:
• Scapholunate ligament disruption with radiocarpal arthritis (a
scapholunate advanced collapse [SLAC] wrist)
• Scaphoid nonunion with radiocarpal arthritis (a scaphoid nonunion advanced collapse
[SNAC] wrist)
• Kienböck disease with collapse
• Unreduced perilunate or transscaphoid perilunate dislocation
• Chronic perilunate dislocations
continued
FIG. 6-G
Radiographs made after a proximal row carpectomy, showing proper positioning of the head of the capitate in the lunate fossa of the radius.
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CRITICAL CONCEPTS | continued
• Failed silicone lunate or
scaphoid arthroplasty
• Osteonecrosis of the scaphoid
(Preiser disease or posttraumatic osteonecrosis)
• Severe flexion contractures
associated with systemic diseases such as cerebral palsy
or arthrogryposis
CONTRAINDICATIONS:
• Degenerative changes on the
head of the capitate or on the
lunate fossa of the distal part
of the radius (Fig. 7).
• Inflammatory arthropathy (e.g.,
rheumatoid arthritis). Typically,
the articular surfaces of the capitate and the distal part of the
radius are involved by inflammatory arthropathies so there is a
high rate of failure of proximal
row carpectomy in patients with
this type of disease2,3.
FIG. 6-H
• An active patient, especially
one who is less than thirty-five
years old. (This is a relative
contraindication.)
PITFALLS:
• Injury to the dorsal sensory
branch of the radial or ulnar
nerve during subcutaneous
dissection.
• Failure to look for and recognize
loss of articular cartilage from
the capitate head and from the
lunate fossa of the distal part of
the radius. If there is evidence
of chondromalacia on those surfaces, either scaphoid excision
with four-corner arthrodesis
or total wrist fusion should be
considered.
• Iatrogenic damage to the articular surface of the capitate or the
lunate fossa of the distal part of
the radius during removal of the
bones in the proximal row.
continued
FIG. 6-I
Figs. 6-H and 6-I At twelve years postoperatively, the patient had limited motion of the
right wrist.
injury to the volar capsule or
ligaments. During the removal
of the carpal bones, care must
be taken to not injure the radiocarpal ligaments, which extend
obliquely from the distal-volar
lip of the radius to the carpus.
The radioscaphocapitate ligament, in particular, can be
visualized in the depths of the
wound and must not be violated.
It courses from the radius and inserts onto the capitate, thereby
preventing postoperative ulnar
translation of the carpus.
After the bones in the proximal row are removed, the capitate settles into the lunate fossa
of the distal part of the radius
(Fig. 5).
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Radial Styloidectomy and
Temporary Pinning of the
Radius to the Distal Carpal Row
Both of these techniques were
frequently recommended in the
past, but neither is necessary. We
do not routinely perform a radial
styloidectomy. Surgeons once
argued that there could be impingement of the trapezium on
the styloid in radial deviation.
However, anatomically, the trapezium is anterior to the styloid.
Furthermore, with an overly generous styloidectomy, there is a
risk of detaching the volar radiocarpal ligaments (specifically the
radioscaphocapitate ligament),
which could lead to ulnar translation of the carpus.
FIG. 6-J
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We do not pin the radius
to the capitate because pinning
does not offer any benefit if a
good capsular closure is performed and also because pinning is associated with the risk
of pin-track infection.
Closure
The capsule is closed with interrupted 2-0 nonabsorbable sutures. Biplanar radiographs are
then made to ensure that the
head of the capitate is seated
in the lunate fossa of the distal
part of the radius. No attempt
is made to replace the extensor
pollicis longus in the third dorsal compartment, and the retinaculum is approximated with
JBJS . ORG
CRITICAL CONCEPTS | continued
• Damage to volar radiocarpal
ligaments (especially the radioscaphocapitate ligament)
during removal of the proximal
row, as this could produce ulnar translation of the carpus.
AUTHOR UPDATE:
There have been no changes in
the surgical technique since publication of the original article.
a 3-0 nonabsorbable suture.
A drain is inserted deep to the
subcutaneous tissue and is removed forty-eight hours postoperatively. The subcutaneous
tissue is approximated with a
FIG. 6-K
Anteroposterior and lateral radiographs made twelve years postoperatively, showing narrowing and sclerosis of the radiocapitate articulation.
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weeks, no immobilization is necessary and an aggressive strengthening program can be initiated.
Three months postoperatively,
the patient can return to full unrestricted activities.
Peter J. Stern, MD
Steven S. Agabegi, MD
Department of Orthopaedic Surgery, University of
Cincinnati College of Medicine, P.O. Box 670212,
Cincinnati, OH 45267-0212. E-mail address for
P.J. Stern: [email protected]
Thomas R. Kiefhaber, MD
Hand Surgery Specialists, 538 Oak Street, Suite
200, Cincinnati, OH 45219
Michael L. DiDonna, MD
El Paso Orthopaedic Surgery Group, 1720 Murchison, El Paso TX 79902
FIG. 7
Capitolunate joint-space narrowing and sclerosis (arrows) are a contraindication to proximal row carpectomy.
3-0 absorbable suture, after which
the skin is closed. A bulky dressing, extending from the fingertips
to the midpart of the forearm, is
applied. A volar plaster splint
is molded to maintain the wrist
in 10° of extension. The tourniquet is then deflated (Figs. 6-A
through 6-K).
Postoperative Management
The procedure can be done in either an inpatient or an outpatient
setting. The patient returns one
week after the surgery for the
wound to be checked and the
dressing to be changed. Digital
motion is encouraged after the
first dressing change. The wrist is
immobilized for three weeks, after
which a range of motion of the
wrist is initiated, preferably with
the supervision of a qualified
hand therapist. The patient wears
a neutral thermoplastic wrist
splint, when he or she is not exercising the wrist, for an additional
three weeks. If there is wrist swelling, an elastic garment can be applied for edema control. By six
The authors did not receive grants or outside funding in support of their research or preparation of
this manuscript. They did not receive payments or
other benefits or a commitment or agreement to
provide such benefits from a commercial entity.
No commercial entity paid or directed, or agreed
to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
The line drawings in this article are the work of
Joanne Haderer Müller of Haderer & Müller
([email protected]).
doi:10.2106/JBJS.E.00261
REFERENCES
1. Wyrick JD, Stern PJ, Kiefhaber TR. Motionpreserving procedures in the treatment of
scapholunate advanced collapse wrist: proximal row carpectomy versus four-corner arthrodesis. J Hand Surg [Am]. 1995;20:965-70.
2. Imbriglia JE. Proximal row carpectomy.
Technique and long-term results. Atlas Hand
Clinics. 2000;5:101-9.
3. Imbriglia JE, Broudy AS, Hagberg WC,
McKernan D. Proximal row carpectomy: clinical
evaluation. J Hand Surg [Am]. 1990;15:426-30.
Downloaded from www.ejbjs.org on September 3, 2005
This is an enhanced PDF from The Journal of Bone and Joint Surgery
The PDF of the article you requested follows this cover page.
Extensor Mechanism Allograft Reconstruction After Total Knee
Arthroplasty
R. Stephen J. Burnett, Richard A. Berger, Craig J. Della Valle, Scott M. Sporer, Joshua J. Jacobs, Wayne G.
Paprosky and Aaron G. Rosenberg
J Bone Joint Surg Am. 87:175-194, 2005. doi:10.2106/JBJS.E.00442
This information is current as of September 3, 2005
Reprints and Permissions
Click here to order reprints or request permission to use material from this
article, or locate the article citation on jbjs.org and click on the [Reprints and
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The Journal of Bone and Joint Surgery
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www.jbjs.org
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COPYRIGHT © 2005
BY
THE JOURNAL
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BONE
AND JOINT
SURGERY, INCORPORATED
Extensor Mechanism
Allograft Reconstruction
After Total Knee Arthroplasty
Surgical Technique
By R. Stephen J. Burnett, MD, FRCS(C), Richard A. Berger, MD, Craig J. Della Valle, MD, Scott M. Sporer, MD,
Joshua J. Jacobs, MD, Wayne G. Paprosky, MD, and Aaron G. Rosenberg, MD
Investigation performed at the Department of Orthopedic Surgery, Rush University Medical Center, Chicago, Illinois
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 2694-2699, December 2004
INTRODUCTION
Extensor mechanism disruption is a devastating complication of total knee arthroplasty. Multiple techniques for repair or reconstruction of a deficient extensor mechanism have been described in
association with total knee arthroplasty; however, few have been
able to reliably restore a functional extensor mechanism1. Despite
encouraging results reported for direct repair in native knees, attempts at primary repair following a total knee arthroplasty rarely
restore extensor function. The use of local autogenous tissue to
augment a primary repair has been recommended. These patients
have frequently undergone multiple previous knee procedures, and
these local autogenous tissues may be compromised and unsuitable
for use.
Emerson et al.2,3 reported on the use of a complete knee extensor
mechanism allograft in total knee arthroplasty to reconstruct the deficient extensor mechanism. Although the early clinical results were
promising, extensor lag occurred early. Nazarian and Booth4 modified
the technique described by Emerson et al., recommending that the allograft be tightly tensioned in full extension, and they reported improved early results. The host tissue-allograft junctions recently have
been studied5, and the findings have provided useful information in
support of this technique.
In the present report, we describe the surgical technique
that we have modified and currently use6 to reconstruct the deficient extensor mechanism with an extensor mechanism allograft
that is tightly tensioned with the knee in full extension. The critical
concepts, pitfalls, and technical aspects of this technique are
presented.
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ABSTRACT
BACKGROUND:
Disruption of the extensor mechanism is an uncommon but catastrophic complication of total
knee arthroplasty. We evaluated
two techniques of reconstructing
a disrupted extensor mechanism
with the use of an extensor mechanism allograft in revision total
knee arthroplasty.
METHODS:
Twenty consecutive reconstructions with the use of an extensor
mechanism allograft consisting
of the tibial tubercle, patellar tendon, patella, and quadriceps tendon were performed. The first
seven reconstructions (Group I)
were done with the allograft minimally tensioned. The thirteen subsequent procedures (Group II)
were performed with the allograft
tightly tensioned in full extension.
All surviving allografts were evaluated clinically and radiographically
after a minimum duration of
follow-up of twenty-four months.
continued
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ABSTRACT | continued
RESULTS:
All of the reconstructions in Group
I were clinical failures, with an average postoperative extensor lag
of 59° (range, 40° to 80°) and an
average postoperative Hospital for
Special Surgery knee score of 52
points. All thirteen reconstructions in Group II were clinical
successes, with an average postoperative extensor lag of 4.3°
(range, 0° to 15°) (p < 0.0001)
and an average Hospital for Special Surgery score of 88 points.
Postoperative flexion did not differ
significantly between Group I (average, 108°) and Group II (average, 104°) (p = 0.549).
FIG. 1
CONCLUSIONS:
The results of reconstruction with
an extensor mechanism allograft
after total knee arthroplasty depend on the initial tensioning of
the allograft. Loosely tensioned
allografts result in a persistent extension lag and clinical failure. Allografts that are tightly tensioned
in full extension can restore active
knee extension and result in clinical success. On the basis of the
number of knees that we studied,
there was no significant loss of
flexion. Use of an extensor mechanism graft for the treatment of a
failure of the extensor mechanism
will be successful only if the graft
is initially tensioned tightly in full
extension.
INITIAL EVALUATION
A deficient extensor mechanism
in association with a total knee
arthroplasty is one of the most
challenging problems that the
orthopaedic surgeon who performs joint replacement surgery
Assessment of prior incisions over the knee and a careful examination are essential preoperatively when considering revision surgery.
FIG. 2
A complete fresh-frozen, nonirradiated knee extensor mechanism allograft that includes
the tibia, patellar tendon, patella, and quadriceps tendon is used.
may encounter. The patient is
initially evaluated with a history,
directed physical examination of
the knee and extremity, radiographs, and adjunctive investigations. The history should focus
on obtaining information about
prior extensor mechanism procedures or surgery and the prior
and current function of the knee.
Symptoms of instability, givingway, and an inability to extend
the knee should be sought. The
nature of previous surgeries and
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FIG. 3
Use of the previous incision is preferred. We use a sterile tourniquet as it is easily removed for the allograft-host proximal graft repair.
the duration of extensor dysfunction should be determined.
Prior operative reports should be
reviewed and scrutinized for the
extensor mechanism and how it
was managed in previous surgeries. A history of infection—remotely or in association with
prior surgery of the knee—warrants further investigation.
Medical comorbidities or immunosuppressive therapy that
may impact on wound-healing
should be sought. On physical
examination, evaluation of the
gait pattern and the use of walking aids are assessed. Prior incisions over the knee (Fig. 1) and
active and passive range of motion are recorded. The presence
of an extensor lag should be carefully measured, and the passive
amount of full extension that is
able to be demonstrated should
be noted. The presence of a flexion contracture and the inability
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to passively extend the knee are
noted. The tracking of the extensor mechanism during rangeof-motion testing should be
examined closely, as malrotation
of the components of the total
knee arthroplasty may be a factor
in the extensor mechanism failure. Radiographs are evaluated
for component alignment, fixation, sizing, remaining host-bone
stock, and the design of components. The extensor mechanism
and patellar position are evaluated for patella infera, patella
alta, and the presence or absence
of a patella. In addition, the presence of heterotopic ossification
involving the extensor mecha-
FIG. 4
The host extensor mechanism is sharply dissected longitudinally in the midline, through
the patellar tendon and quadriceps tendon.
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nism is noted. The presence of
suture anchors or staples around
the insertion of the patellar tendon into the tibial tubercle is often an ominous radiographic
sign. Patellar tracking is evaluated on the axial radiograph. If
there is any concern about malrotation of the components, we
recommend an axial computed
tomography scan of the femoral
and tibial components to evaluate for component internal
malrotation7. The erythrocyte
sedimentation rate and serum
C-reactive protein level are measured to evaluate for infection. If
these are elevated, a knee aspiration is performed for cell count
and synovial fluid culture.
Decision to Reconstruct the
Extensor Mechanism with Use of
an Extensor Mechanism Allograft
Once the diagnosis and etiology
of a deficient extensor mechanism is made, we discuss the surgical options with each patient.
The indications and contraindications are carefully reviewed.
Ongoing infection or repeated
unsuccessful staged reimplantation procedures with persistent
infection are contraindications
to this procedure. The inability
to comply with postoperative
immobilization and a directed
physical therapy program are
also contraindications. In these
instances, bracing and nonoperative treatment or knee arthrodesis are discussed with the
patient. If the patient is a candidate for surgery, the procedure
and postoperative rehabilitation
are discussed preoperatively. If
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FIG. 5
The remaining patella or
remnant is split in the
midline with a saw, in line
with the proximal and distal split.
FIG. 6
A saw is used to split the patella from anterior to posterior in a longitudinal fashion, in
line with the extensor mechanism arthrotomy.
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the patient has an intact native
patella and a deficient patellar
tendon, alternative allograft extensor mechanism reconstructions with the use of an Achilles
tendon-allograft calcaneal bone
block8 may also be considered.
We always plan to be prepared
to revise and address malrotated
total knee arthroplasty components at the time of revision
surgery.
FIG. 7
The soft tissues around the patella are preserved in continuity with the retinaculum on
the medial and lateral sides of the two fragments.
FIG. 8
Two sleeves of soft tissue are
reflected off the proximal part
of the tibia in the region of the
tibial tubercle, again maintaining two flaps for later closure.
Allograft Extensor
Mechanism
Preoperatively, we order an allograft extensor mechanism of
the entire knee that includes the
tibia or a large portion of the
proximal part of the tibia, the
patellar tendon, the patella, and
at least 5 cm of quadriceps tendon (Fig. 2). The allografts are
fresh-frozen, nonirradiated specimens (Allosource, Centennial,
Colorado). We prefer the freshfrozen over the freeze-dried allografts, given the results previously described by Emerson et
al.2,3 and concerns that freezedrying may weaken the allograft
tissue, leading to complications
and failure. The potential to generate a greater risk of a host immune response than occurs with
fresh-frozen specimens has also
been a concern. Before the patient comes into the operating
room and before the induction
of anesthesia, we visually inspect
the allograft to ensure that there
is an adequate specimen. Specifically, there must be a proximal
tibial allograft that will allow
a bone-block harvest of at least
5 cm attached to the patellar ten-
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FIG. 9
Medial and lateral sleeves have been created, allowing direct exposure to the implants
and the anterior aspect of the tibia and tubercle.
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use of a previous incision is recommended when present. If
multiple incisions are present,
we use the most lateral incision
closest to the midline, in order
to preserve blood supply to the
skin. Often these are knees that
have had multiple operations
and may have undergone a previous gastrocnemius flap or other
soft-tissue coverage procedure.
In this instance, we are careful
not to disrupt the blood supply
to this coverage and we have a
plastic reconstructive surgeon
available to assist during the exposure. The dissection is carried
down in the midline with conservative elevation of skin and
subcutaneous flaps. The retinaculum and extensor mechanism
are then exposed. A midline inci-
don and at least 5 cm of allograft
quadriceps tendon proximally.
SURGICAL TECHNIQUE
Patient Positioning
We place the patient supine on
the operating table, with a sterile
pneumatic tourniquet around
the thigh and a padded bump beneath the trochanter. The leg is
prepared and draped free, and
the foot is held in a leg holder
during the procedure to allow
variable amounts of flexion and
extension.
Exposure of the Knee
The pneumatic tourniquet is inflated after exsanguination with
an Esmarch bandage and flexion
of the knee. Previous incisions
are marked (Fig. 3). We prefer a
midline skin incision; however,
FIG. 10
Removal of a malrotated femoral component. If malrotated components are left unaddressed, extensor mechanism maltracking will continue, with increased stress on the allograft and early failure.
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FIG. 11
The allograft tibial block is marked for a rectangular cut of 6 to 8 x 2 x 2 cm.
FIG. 12
The rectangular block is then marked for a later bevel cut proximally to create the dovetail.
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sion is performed through the
remaining extensor mechanism
(the quadriceps tendon and patellar tendon or scar tissue), creating medial and lateral flaps of
retinaculum and exposing the
joint (Fig. 4). Culture specimens
are obtained and sent to the microbiology laboratory, and synovial fluid is assessed for cell
count. If there is a native patella
or a remnant, it is osteotomized
in a longitudinal fashion in the
midline (Fig. 5), in line with the
midline soft-tissue retinacular
incision (Figs. 6 and 7). The patellar bone is then shelled out
and carefully removed, preserving the soft tissues in continuity
with the medial and lateral retinacular flaps. This bone is kept
for autogenous bone graft as necessary. The medial and lateral
gutters and suprapatellar pouch
are recreated. The midline incision is carried proximally into
the host quadriceps, again maintaining a medial and lateral
sleeve of tissue for later closure.
The midline incision is carried
over the host tibial tubercle with
elevation of medial and lateral
soft-tissue flaps (Figs. 8 and 9).
Total Knee Arthroplasty
Component Revision
and Reimplantation
Revision total knee arthroplasty
then proceeds as necessary. Rotation of the femoral and tibial
components is assessed, and our
threshold for revision of malrotated components is very low,
as they can contribute to extensor mechanism maltracking (Fig.
10). Balancing of flexion and ex-
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tension gaps is then performed,
with careful attention to obtaining full passive extension of the
knee. Trial components are removed, and definitive components are implanted in a routine
fashion. The final polyethylene
liner is inserted prior to insertion of the extensor mechanism
allograft. We have used this procedure with primary cruciateretaining, posterior stabilized,
revision constrained condylar
designs, and constrained hinge
knee designs. If stemmed components are being inserted, it
may be preferable to prepare the
host tibial bone trough and place
the fixation wires through the
tibia at this stage, followed by
insertion of the stemmed tibial
component.
The revision total knee arthroplasty implants are now in
place, and the host tissues are
next prepared to accept the extensor mechanism allograft.
Allograft Preparation
on the Back Table
Simultaneous with the revision
or placement of the total knee
arthroplasty components, the
allograft specimen may be prepared on the back table. The host
tibial trough is not made until
we have harvested the allograft
tibial block, in order to ensure
a press-fit of our allograft tibial
block. We first mark with a
marking pen over the allograft
tibial tubercle and proximal part
of the tibia our planned harvest
of the allograft tibial bone block,
in a rectangular fashion. The
length of the block should be ap-
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FIG. 13
Photograph of the rectangular tibial cut marked for the finishing bevel cut.
FIG. 14-A
Figs. 14-A through 14-D Finished cut of the tibial allograft segment with a proximal dovetail cut. Fig. 14-A Lateral view.
FIG. 14-B
Oblique view.
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FIG. 14-C
FIG. 14-D
Fig. 14-C Posterior aspect.
Fig. 14-D Anterior aspect.
proximately 6 to 8 cm from the
tibial articular surface of the allograft to the distal cut. The width
of the block is 2 cm, and the depth
is 2 cm (Fig. 11). We cut on the
conservative side and make the
cuts slightly larger if necessary, as
these may be trimmed or downsized as needed. With use of a
small thin microsagittal saw, the
allograft block is harvested from
the allograft tibia (Fig. 12), with
careful attention so as not to damage the allograft patellar tendon
(Fig. 13). The proximal bevel or
“dovetail” on the allograft bone
block is not created during this
part of the harvest, as it is simpler
to perform once the graft has been
removed from the allograft tibia.
Once the allograft bone
block has been carefully removed from the allograft tibia,
we next prepare the bevel, or
dovetail, on the proximal aspect
of the removed bone block (Fig.
12). This serves two purposes.
The first is to lock into the host
native tibial trough and avoid
graft escape. The second is to allow a press-fit of the graft into
the native tibia. Using a marking
pen (Fig. 13), we draw an angle
of 30° to 40° (from the perpendicular of the graft) as a bevel
and cut it carefully with the thin
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saw blade. The length of the bevel
is approximately 20 to 25 mm
(Figs. 14-A through 14-D).
Two number-2 nonabsorbable sutures are then placed in a
running, locked fashion, as described by Krackow et al.9, along
the medial and lateral aspects of
the allograft quadriceps tendon,
exiting out proximally. These sutures are kept long, and they are
placed so that the assistant can
apply tension and pull the allograft tightly proximally once
it has been secured into the prepared tibial bed.
The graft and the proximal
two sutures are then placed care-
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CRITICAL CONCEPTS
INDICATIONS:
• Disruption of the extensor
mechanism (extensor lag)
that is not amenable to or
has failed a primary repair
• Patellar tendon rupture, avulsion, or prior excision
• Quadriceps tendon rupture,
avulsion, or prior excision
• Patellar fragmentation or
nonreconstructible patellar
fracture
• Severe heterotopic ossification
of the extensor mechanism
• Previous patellectomy with
a total knee arthroplasty
and symptomatic extensor
lag
• Severe patella infera and arthrofibrosis of the extensor
mechanism
• Conversion of previous knee
arthrodesis to a total knee
replacement with a fibrosed or
deficient extensor mechanism
FIG. 15
The host proximal tibial trough is marked. Careful attention to the location of this trough in the
region of the tibial tubercle or slightly medial to it will allow for improved patellar tracking.
continued
fully in a basin on the back table,
and attention is turned to the
preparation of the proximal part
of the host tibia.
Preparation of the Host
Proximal Tibial Trough
Using a marking pen, we mark
out the host proximal tibial
trough (Fig. 15). We typically attempt to place the allograft tibial
tubercle in a position that is close
to, or slightly medial to, the position of the native tibial tubercle.
In addition, we attempt to leave
at least 15 mm of host bone intact below the tibial component
anteriorly to resist proximal migration or escape of the graft, although this 15 mm of bone is not
always possible in the revision
setting with associated bone loss.
The rectangular tibial trough is
then marked out for a length of
5 cm and a width of just less than
2 cm and a depth of 2 cm. Proximally, the host bone is beveled
(Fig. 16) to accept a press-fit of
the beveled, or dovetailed, allograft bone block (Fig. 17). This
bevel in the host bone should be
created with dimensions slightly
smaller than the allograft bone
block, in order to allow a press-
fit (Fig. 18). Two or three 18gauge stainless steel wires are
then placed through drill-holes
in the tibia from medial to lateral (Fig. 19). These wires must
pass deep to the tibial trough. If a
stemmed tibial component is being used, it is easier to drill and
place these wires prior to inserting the stemmed component.
The allograft extensor mechanism is then inserted into the
host tibial trough and is gently
press-fit with a bone tamp or
punch, in an “up and in” fashion,
in order to lock the dovetail in
place. The wires are then twisted,
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CRITICAL CONCEPTS | continued
CONTRAINDICATIONS:
• Ongoing infection or concurrent infection of a total knee
replacement at or near the
operative site
• Reconstructible extensor
mechanism with primary
repair or local autogenous
reinforcement tissue
• An unreliable, noncompliant
patient who is unable to cooperate with postoperative
rehabilitation
continued
FIG. 16
The proximal host tibial trough is also beveled under to allow for a locking fit of the allograft tibial block. A small curet is useful to complete this bevel.
tightened, cut, and bent over
against bone to avoid irritation
to the soft tissues (Fig. 20). Alternatively, a small-fragment
cortical screw and washer may
be added to the fixation at the
surgeon’s preference. This creates a drill-hole in the allograft,
and we prefer to avoid this stressriser, despite the added security
of the screw fixation.
Once we have secured the
allograft bone into the host tibia,
attention is turned to the proxi-
mal quadriceps medial and lateral sleeves and retinaculum.
Preparation and Tensioning
of the Host Distal Quadriceps
Similar to the retention sutures
placed in the allograft quadriceps, the host distal quadriceps
medial and lateral soft-tissue
sleeves are prepared. We again use
a number-2 nonabsorbable suture
(FiberWire; Arthrex, Naples, Florida) and place a short running
Krakow suture into both the me-
dial and lateral retinaculum in the
distal quadriceps muscle-tendon
junction. This allows a second
assistant to “pull down” the host
quadriceps mechanism (Fig. 21),
effectively tensioning the distal
host extensor mechanism (Fig.
22). The two previously placed
allograft quadriceps sutures are
pulled tightly with the knee in full
extension (Figs. 23-A and 23-B).
With use of a suture passer, these
sutures are then pulled from distal
to proximal, out and up through
the more proximal host quadriceps. This pulls the allograft
quadriceps up and under the host
quadriceps, and simultaneously
pulls or tensions the host quadriceps distally (Fig. 24). With this
tension maintained, the allograft
is then sutured in place beneath
the host quadriceps with number5 nonabsorbable suture, in a
“vest-over-pants” fashion (see
Fig. 24). Throughout this suture
repair, the two assistants maintain tension on their respective
retention sutures, in order to
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FIG. 17
Completed anterior tibial trough, which is ready to accept the allograft extensor mechanism.
FIG. 18
The allograft tibial block is press-fit into the host tibial trough.
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FIG. 19
Fixation of the tibial allograft with stainless steel wires, which are drilled through the tibia, beneath the allograft.
FIG. 20
The wire fixation is secured after insertion of the allograft bone into the host tibia.
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CRITICAL CONCEPTS | continued
PITFALLS:
• A fresh-frozen, nonirradiated
allograft specimen consisting of a quadriceps tendon,
patella, patellar tendon,
and tibial bone is required.
It is preferable to have at
least 5 cm of quadriceps
tendon allograft for suture repair into the host quadriceps
mechanism.
• We recommend use of a midline approach through the extensor mechanism anteriorly.
Large medial and lateral flaps
that provide excellent tissue
for closure over the extensor
mechanism allograft are developed. If there is native patella
remaining, this is osteotomized transversely in line with
the midline arthrotomy. The patellar remnant is then shelled
out and removed.
• Component revision is often
necessary. It is important
that the knee be able to be
passively brought to full extension with the trial implants
in place, in order to ensure
full extension is attainable
postoperatively.
• It is important that the proximal aspect of the allograft tibial bone and the bone trough
on the native tibia be dovetailed in order to lock, or
press-fit, the allograft into the
native tibia and resist proximal migration.
• When the allograft is sutured proximally into the
native quadriceps, tension
must be maintained on the allograft with the knee in full
extension.
continued
FIG. 21
Two running, locked Krakow sutures are placed into the medial and lateral host quadriceps retinaculum.
maintain tension with the knee
in the extended position. Once
the proximal aspect of the allograft is secured, the repair is
continued along the medial and
lateral sides. However, the repair
is performed with the host retinaculum brought over the top
of the allograft, in order to cover
the allograft tissues as much as
possible with the medial and lateral sleeves of the host retinaculum. We find that we are usually
able to completely cover the allograft with these host sleeves
that have been preserved, in addition to suturing the allograft
underneath these tissues (Fig.
25). Distally, the host tissues are
closed over the wires and allograft bone block.
CLOSURE
We prefer to not flex the knee to
“test” our repair once it is completed. This should be avoided in
order to not stress the repair and
attenuate the allograft host junction. The subcutaneous tissues
are closed in routine fashion. The
skin is closed with staples. If the
skin over the distal incision is
tenuous, nonabsorbable suture
may be used.
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CRITICAL CONCEPTS | continued
• It is not desirable to have
an overly long allograft quadriceps tendon. A segment that
is too long will end up being
sewn proximally into the rectus femoris muscle instead
of into the host quadriceps
tendon.
• The host retinaculum medial
and lateral flaps should be
sewn over the allograft as
much as possible in order to
cover the allograft.
• The knee should not be flexed
intraoperatively to assess the
flexion of the construct. The
patient is managed with immobilization of the knee in full extension with touch-down
weight-bearing for eight weeks,
and then a directed physical
therapy program is begun.
FIG. 22
These two sutures allow the host extensor mechanism to be tensioned by pulling distally.
• The allograft patella is not resurfaced in order to avoid creating a stress-riser in it.
continued
FIG. 23-A
Two sutures placed in the allograft quadriceps allow the allograft to be tensioned proximally.
POSTOPERATIVE CARE AND
REHABILITATION
In the operating room at the
completion of the procedure, the
knee is placed in full extension.
We prefer to use a knee immobilizer that is customized to the size
and diameter of the extremity.
This allows for complete immobilization of the knee in full extension and permits access to the
wound postoperatively. A poorfitting brace allows for flexion
and movement, which should be
avoided in the immediate postoperative period. Alternatively,
a cylindrical fiberglass cast may
be placed on the limb in the op-
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FIG. 23-B
The host extensor mechanism and allograft are pulled by two separate assistants into an extension position.
FIG. 24
The sutures in the allograft quadriceps are pulled under the host quadriceps and out proximally through the host extensor mechanism.
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FIG. 25
The host medial and lateral sleeves of retinaculum, if preserved during the surgery, serve to cover the allograft completely, reducing the exposure of the allograft to the subcutaneous tissues.
erating room. The disadvantage
of the cast is that it must be removed if there are concerns
about the wound and in order
to change the dressing postoperatively. In a patient with borderline compliance, this is the safest
form of immobilization, but it is
often poorly tolerated.
Postoperative physical therapy follows a protocol that we
developed for this procedure.
Patients are maintained with the
knee in full extension for eight
weeks after surgery. During this
period, we allow touch-down
weight-bearing only. We have the
patient avoid full weight-bearing
in order to reduce the quadriceps force on the tibial tubercle
and the allograft-host soft-tissue
repair. We do not allow any flexion during this eight-week period. We encourage isometric
static quadriceps contractions.
After eight weeks, 30° of active
flexion is permitted, under the
supervision of a physical therapist, with the patient wearing a
hinged knee brace with a lockout against further flexion. Simi-
CRITICAL CONCEPTS | continued
AUTHOR UPDATE:
This technique has not been modified since the publication of our original
study. We emphasize that success with this technique requires that several
critical aspects be carefully followed. The midline incision and retention of
host medial and lateral retinacular tissue is important. Removing the patellar remnant in this way ensures that medial and lateral flaps remain for
closure, and it improves exposure. Tensioning the allograft tightly in full extension is necessary to help to reduce the risk of allograft attenuation and
extensor lag. Closure of the medial and lateral flaps over the allograft as
much as possible reduces the contact of the allograft with subcutaneous
tissues and, we believe, reduces the risk of infection. We emphasize that
we do not flex the repair once it is completed, as has been recommended
by other authors.
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FIG. 26-A
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FIG. 26-B
FIG. 26-C
Figs. 26-A, 26-B, and 26-C Preoperative radiographs showing a patient with a deficient extensor mechanism (patellar tendon attenuation) and component malrotation with lateral dislocation of the host extensor mechanism.
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FIG. 26-D
FIG. 26-E
FIG. 26-F
Figs. 26-D, 26-E, and 26-F Radiographs made after component revision and reconstruction with an extensor mechanism allograft.
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larly, at eight weeks, patients are
advanced to weight-bearing as
tolerated. During weight-bearing,
we lock the brace in full extension. At twelve weeks, we allow
further active flexion up to a
maximum of 90°, and gentle
quadriceps strengthening exercises are initiated. Passive flexion
is not permitted in order to minimize the chance of graft failure
and early attenuation. Patients
are evaluated at six months and
then on a yearly basis (Figs. 26-A
through 26-F).
NOTE: The authors thank Regina M. Barden, RN, and Margaret Arp for their contribution to the preparation and clinical
support for this study.
R. Stephen J. Burnett, MD, FRCS(C)
Department of Orthopaedic Surgery, Barnes
Jewish Hospital, Washington University, 660
South Euclid Avenue, Campus Box 8233,
St. Louis, MO 63110. E-mail address:
[email protected]
Richard A. Berger, MD
Craig J. Della Valle, MD
Scott M. Sporer, MD
Joshua J. Jacobs, MD
Wayne G. Paprosky, MD
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Aaron G. Rosenberg, MD
Rush University Medical Center, Midwest Orthopaedics, 1725 West Harrison Street, Suite 1063,
Chicago, IL 60612
In support of their research or preparation of this
manuscript, one or more of the authors received
grants or outside funding from Zimmer. In addition, one or more of the authors received payments or other benefits or a commitment or
agreement to provide such benefits from a commercial entity (Zimmer). Also, a commercial entity
(Zimmer) paid or directed, or agreed to pay or
direct, benefits to a research fund, foundation,
educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
The line drawings in this article are the work of
Jennifer Fairman ([email protected]).
JBJS . ORG
mechanism allograft. Clin Orthop Relat Res.
1990;260:154-61.
3. Emerson RH Jr, Head WC, Malinin TI. Extensor mechanism reconstruction with an
allograft after total knee arthroplasty. Clin
Orthop Relat Res. 1994;303:79-85.
4. Nazarian DG, Booth RE Jr. Extensor mechanism allografts in total knee arthroplasty. Clin
Orthop Relat Res. 1999;367:123-9.
5. Burnett RS, Fornasier VL, Haydon CM, Wehrli BM, Whitewood CN, Bourne RB. Retrieval
of a well-functioning extensor mechanism allograft from a total knee arthroplasty. Clinical
and histological findings. J Bone Joint Surg
Br. 2004;86:986-90.
6. Burnett RS, Berger RA, Paprosky WG, Della
Valle CJ, Jacobs JJ, Rosenberg AG. Extensor
mechanism allograft reconstruction after total knee arthroplasty. A comparison of two
techniques. J Bone Joint Surg Am. 2004;
86:2694-9.
doi:10.2106/JBJS.E.00442
REFERENCES
1. Leopold SS, Greidanus N, Paprosky
WG, Berger RA, Rosenberg AG. High rate
of failure of allograft reconstruction of
the extensor mechanism after total knee
arthroplasty. J Bone Joint Surg Am. 1999;
81:1574-9.
2. Emerson RH Jr, Head WC, Malinin TI. Reconstruction of patellar tendon rupture after
total knee arthroplasty with an extensor
7. Berger RA, Crossett LS, Jacobs JJ, Rubash
HE. Malrotation causing patellofemoral complications after total knee arthroplasty. Clin
Orthop Relat Res. 1998;356:144-53.
8. Crossett LS, Sinha RK, Sechriest VF,
Rubash HE. Reconstruction of a ruptured patellar tendon with achilles tendon allograft
following total knee arthroplasty. J Bone Joint
Surg Am. 2002;84:1354-61.
9. Krackow KA, Thomas SC, Jones LC. Ligament-tendon fixation analysis of a new stitch
and comparison with standard techniques.
Orthopedics. 1988;11:909-17.
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This is an enhanced PDF from The Journal of Bone and Joint Surgery
The PDF of the article you requested follows this cover page.
Combined Dorsal and Volar Plate Fixation of Complex Fractures of the
Distal Part of the Radius
David Ring, Karl Prommersberger and Jesse B. Jupiter
J Bone Joint Surg Am. 87:195-212, 2005. doi:10.2106/JBJS.E.00249
This information is current as of September 3, 2005
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COPYRIGHT © 2005
BY
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BONE
AND JOINT
SURGERY, INCORPORATED
Combined Dorsal and
Volar Plate Fixation of
Complex Fractures of the
Distal Part of the Radius
Surgical Technique
By David Ring, MD, Karl Prommersberger, MD, and Jesse B. Jupiter, MD
Investigation performed at Klinik fur Handchirurgie, Bad Neustadt, Germany,
and Massachusetts General Hospital, Boston, Massachusetts
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 1646-1652, August 2004
INTRODUCTION
Some articular fractures of the distal part of the radius are so complex
that a bridging plate1 or even primary wrist arthrodesis2 is considered
to be the best form of treatment (Figs. 1-A and 1-B). These fractures
often have a combination of complex articular and metaphyseal comminution. The articular comminution includes fractures in both the
coronal and the sagittal plane as well as impacted central articular
fragments. The metaphyseal comminution leaves very little support
for the articular fragments, so the surgeon must rely on the implants
to maintain the length of the radius. In this setting, neither external
fixation alone nor a single volar or dorsal implant is likely to provide
adequate stability. We have had some success with combined dorsal
and volar internal fixation.
SURGICAL TECHNIQUE
Intraoperative traction with use of temporary intraoperative external
fixation or skeletal distraction is very helpful. We usually use external
fixation and then keep it in place for three to six weeks after the surgery to provide additional support and to avoid the need for a tight
circumferential dressing (Fig. 2-A).
Such complex fractures usually require simultaneous dorsal and
volar exposure. The dorsal exposure provides direct access to the articular surface. The volar exposure allows interdigitation of the stout
volar cortex—the strongest bone in the distal part of the radius and
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ABSTRACT
BACKGROUND:
Fractures of the distal part of
the radius that are associated
with complex comminution of
both the articular surface and
the metaphysis (subgroup
C3.2 according to the Comprehensive Classification of
Fractures) are a challenge for
surgeons using standard operative techniques.
METHODS:
Twenty-five patients with subgroup-C3.2 fractures that had
been treated with combined dorsal and volar plate fixation were
evaluated at an average of
twenty-six months after the injury. Subsequent procedures
continued
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ABSTRACT | continued
included implant removal in
twenty-one patients and reconstruction of a ruptured tendon
in two patients.
RESULTS:
An average of 54° of extension,
51° of flexion, 79° of pronation,
and 74° of supination were
achieved. The grip strength in
the involved limb was an average of 78% of that in the contralateral limb. The average
radiographic measurements
were 2° of dorsal angulation,
21° of ulnar inclination, 0.8 mm
of positive ulnar variance, and
0.7 mm of articular incongruity.
Seven patients had radiographic
signs of arthrosis during the
follow-up period. A good or excellent functional result was
achieved for twenty-four patients
(96%) according to the rating
system of Gartland and Werley
and for ten patients (40%) according to the more stringent
modified system of Green and
O’Brien.
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one of the few areas where the
surgeon is likely to be able to
judge appropriate length and
alignment and to achieve boneto-bone contact for additional
stability3.
Volar exposure is usually
achieved with the approach described by Henry4 in line with the
flexor carpi radialis, but a volarulnar exposure or an extended
carpal tunnel release5 can be used
when exposure to the volar lu-
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nate facet is more important
than exposure to the radial styloid. Many patients also have a
carpal tunnel syndrome, which is
addressed with a volar-ulnar exposure but requires a second incision in patients treated through
a Henry exposure in order to
avoid injury to the palmar cutaneous branch of the median
nerve (Fig. 2-B).
Extending the skin incision
across the transverse wrist flex-
CONCLUSIONS:
Combined dorsal and volar
plate fixation of the distal part
of the radius can achieve a stable, mobile wrist in patients
with very complex fractures.
The results are limited by the
severity of the injury and may
deteriorate with longer followup. A second operation for implant removal is common, and
there is a small risk of tendonrelated complications.
FIG. 1-A
Figs. 1-A and 1-B Radiographs of a forty-year-old man who sustained a fracture of the
left, nondominant wrist in a skiing accident. (Reprinted with permission of David Ring
and Jesse B. Jupiter.) Fig. 1-A A posteroanterior radiograph made at the time of injury
demonstrates complex metaphyseal and articular comminution with substantial
displacement.
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CRITICAL CONCEPTS
INDICATIONS:
The indication for combined dorsal and volar plate fixation is a
fracture of the distal part of the
radius with complex comminution of the articular surface and
metaphysis for which a single
dorsal or volar plate would not
be sufficient. Fortunately, these
are very uncommon fractures.
CONTRAINDICATIONS:
There are no absolute contraindications to combined dorsal
and volar plate fixation of the
distal part of the radius; however, the surgeon may need to
strongly consider alternatives
such as a bridging plate or primary wrist arthrodesis, depending on the complexity of the
fracture. In general, we usually
attempt fixation initially, given
that even a small amount of
wrist motion will enhance the
function of the upper limb, and
we reserve arthrodesis as a salvage procedure. Open fractures
are associated with a greater
risk of infection when there are
devitalized central articular fragments, but an attempt to salvage even devitalized joint
fragments with débridement, fixation, and parenteral antibiotics
is reasonable.
FIG. 1-B
The lateral radiograph also demonstrates substantial metaphyseal comminution.
ion creases is helpful when a
more extensive exposure is
needed. These flexion creases
should be crossed obliquely. The
radial edge of the distal portion
of the origin of the flexor pollicis
longus is elevated from the radius to increase exposure of the
pronator quadratus. The radial
edge of the radius is exposed, and
the radial edge of the pronator
quadratus is incised.
The pronator quadratus is
then elevated subperiosteally.
Leaving the periosteum attached
to the undersurface of the pronator may provide additional stout
tissue for repair as repair of
muscle fibers alone is difficult
and often impossible. Release or
z-lengthening of the brachioradialis can reduce the radial deviation stress on the fragments
(Fig. 2-C).
All fragments of the volar
metaphyseal cortex are saved and
continued
used as puzzle pieces to judge
restoration of length and alignment. They are wedged into
place and provisionally fixed
with smooth Kirschner wires if
necessary (Fig. 2-D).
Dorsally, a longitudinal in-
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FIG. 2-A
Figs. 2-A through 2-T Reprinted with permission of David Ring and Jesse B. Jupiter. Fig. 2-A External fixation provides both continuous intraoperative traction as well as postoperative support and protection. A single large incision for insertion of both Schanz screws helps to
protect the radial sensory nerve and avoid impaling underlying muscles and tendons. Volar access is most commonly obtained with the
Henry interval between the flexor carpi radialis and the radial artery. The skin is incised in line with the flexor carpi radialis across the transverse wrist creases obliquely. The superficial radial artery and the palmar cutaneous branch of the median nerve should be protected in the
distal portion of the wound. The flexor carpi radialis tendon sheath is incised to gain access to the deeper structures. In this case, a second incision in the palm was used to release the carpal tunnel in order to avoid injury to the palmar cutaneous branch of the median nerve.
FIG. 2-B
The fat overlying the pronator quadratus and the flexor pollicis longus are swept ulnarward bluntly. For very proximal exposure, the most radial and distal portion of the flexor pollicis longus muscle is elevated from the radius (forceps). The radial edge of the radius is exposed
(Hohmann retractors). The pronator quadratus is then incised on its radial margin and is elevated subperiosteally.
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FIG. 2-C
The brachioradialis tendon can be released or z-lengthened to facilitate restoration of length and ulnarward inclination of the distal radial
articular surface.
FIG. 2-D
This photograph demonstrates the difficulty involved with aligning and stabilizing these complex fractures. Direct cortical contact between
the radial diaphysis and the distal part of the radius is possible only in a very small area in the center. On the ulnar side (Freer elevator and
left index finger), a large fragment of volar-ulnar cortex has been repositioned and provisionally stabilized with a smooth Kirschner wire in
order to help the surgeon to judge restoration of length and alignment and perhaps provide additional stability.
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FIG. 2-E
The dorsal incision is in line with the third metacarpal and the radial diaphysis (and the Lister tubercle when palpable). A long incision is
needed to provide access for both dorsal and radial implants and a dorsal capsulotomy.
FIG. 2-F
The development of full-thickness skin flaps protects the radial and ulnar sensory nerve branches and provides broad access to the dorsal
surface of the distal part of the radius.
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FIG. 2-G
The extensor pollicis longus is identified, mobilized, and transposed dorsally and radially into the subcutaneous tissues, where it is left at
the end of the procedure.
FIG. 2-H
The fourth dorsal compartment is elevated subperiosteally off of the distal part of the radius, but the attachment of the dorsal capsule to
the dorsal fracture fragments is maintained.
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FIG. 2-I
A longitudinal incision of the dorsal capsule has been created, and the dorsal-ulnar distal radial fragments are elevated. One can see a
piece of metaphyseal cortical bone that was removed from the joint (near the Hohmann retractor, to the left) and impacted central articular
fragments below the forceps under the dorsal-ulnar fragment.
FIG. 2-J
The forceps (right hand) is elevating the dorsal portion of the scapholunate interosseous ligament, which was avulsed from the scaphoid at
the time of the injury. A dorsal capsulotomy allows identification and treatment of any intercarpal injuries.
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FIG. 2-K
The alignment of the volar articular fragments (at the tip of the suction) can be monitored and adjusted through this exposure.
FIG. 2-L
Impacted central articular fragments are identified, realigned, and supported. In complex fractures such as this one, these fragments are
removed, replaced once the major volar fragments have been realigned and secured, and supported with both fixed-angle fixation devices
and bone graft.
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FIG. 2-M
The volar plate can assist with realignment of the volar articular fragments. The volar fragments tend to rotate on their volar capsular attachments into dorsal angulation. The distal screws are applied in an anatomic position, with the proximal portion of the plate away from
the bone.
FIG. 2-N
When the proximal portion of the plate is brought down to bone, the alignment of the volar articular fragments is improved. The alignment
of the volar cortex is checked, and the plate is secured proximally.
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FIG. 2-O
The radial styloid fragment may benefit from a separate fixation device specifically to control it. Good access to the radial styloid is available between the first and second dorsal compartments. In this patient, a plate with angular stable screws has been applied to the radial
styloid in this area.
FIG. 2-P
With the radial styloid and the volar fragments realigned and stabilized, the metaphyseal and articular defects are more obvious.
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FIG. 2-Q
The impacted central articular fragments are replaced and are supported by the angular stable screws and by bone placed into the metaphyseal defect. If all of the bone fragments that are retrieved are saved and replaced at the end of the operation, additional bone graft and
substitutes are often unnecessary.
FIG. 2-R
Prior to repositioning and fixation of the dorsal ulnar fragments, the scapholunate ligament is reattached to the scaphoid with use of a suture anchor.
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FIG. 2-S
The dorsal cortex with the dorsal articular margin is then repositioned and is repaired with a dorsal plate. Angular stable screws in the distal part of the limb provide additional support for the articular fragments.
FIG. 2-T
The traction across the external fixator is diminished so that the extrinsic extensor and flexor tendons are not excessively tight. The wrist is
placed in a position of neutral or slight extension to facilitate motion and rehabilitation of the hand.
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allow for a generous capsulotomy to provide good visualization of the joint (Fig. 2-E). Broad
skin flaps are developed to protect the radial sensory and dorsal
ulnar cutaneous nerve branches
while allowing broad access to
the dorsal aspect of the radius
(Fig. 2-F).
FIG. 3-A
Figs. 3-A and 3-B Radiographs made after operative fixation of the fracture demonstrated in Figures 1 and 2. (Reprinted with permission of David Ring and Jesse B. Jupiter.) Fig. 3-A An anteroposterior radiograph reveals adequate restoration of the length
and alignment of the radius despite complex articular and metaphyseal comminution.
cision is centered over the Lister
tubercle, or in line with the third
metacarpal and radial shaft given
that the Lister tubercle is de-
formed or cannot be palpated in
the majority of these complex
fractures. The incision extends
distal to the radiocarpal joint to
FIG. 3-B
The lateral radiograph demonstrates
the support of the articular surface by
multiple fixed-angle subchondral
screws. Follow-up radiographs are not
available as this patient was treated
very recently.
CRITICAL CONCEPTS | continued
PITFALLS:
The major pitfall in the treatment of this injury is underestimation of its complexity. The surgeon should be prepared to find cortical bone in the joint,
joint fragments impacted deep into the metaphysis, and pieces of metaphyseal bone distributed throughout the area as if the distal part of the radius
had exploded. If a physician is not prepared to deal with this degree of complexity, the patient should be referred to a surgeon who has greater experience with the injury. If the complexity is discovered in the operating room, an
external fixator should be applied for comfort and stability, the surgeon
should consider releasing the carpal tunnel, and the patient should be referred for definitive treatment.
continued
The extensor pollicis longus is identified and mobilized
(Fig. 2-G). It is transposed dorsally and radially into the subcutaneous tissues and left there at
the end of the operation. The ra-
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dial wrist extensors are retracted
radially. An attempt should be
made to keep the fourth dorsal
compartment intact by elevating
it subperiosteally in the ulnar direction (Fig. 2-H).
The wrist capsule can be divided in a myriad of ways, but in
most cases it makes sense to incise it longitudinally, leaving it
attached to the dorsal fracture
fragments. The fragments and
capsule can then be retracted to
expose the joint (Fig. 2-I). Expo-
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sure of the joint is more difficult
through the volar wound, primarily because a volar capsulotomy
is not advisable. The volar capsule is stouter and structurally
more important than the dorsal
capsule. Some joint exposure can
be obtained volarly by mobilizing the fracture fragments or by
mobilizing the radial shaft and
rotating it out of the way, but this
is not necessary when a combined dorsal and volar exposure
is used.
Joint exposure allows identification and treatment of a
scapholunate ligament injury
when one is present (Fig. 2-J), allows the surgeon to be sure that
the volar articular fragments are
properly rotated (Fig. 2-K), and
permits identification and realignment of impacted central
articular fragments (Fig. 2-L).
It is sometimes useful to
place the distal screws first so
that bringing the plate down to
the bone proximally will improve
FIG. 4-A
Figs. 4-A through 4-F Long-term follow-up radiographs of a
case similar to that shown in Figures 1 and 3. (Reprinted with
permission of David Ring and Jesse B. Jupiter.) Fig. 4-A The appearance of the fracture on the posteroanterior radiograph.
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FIG. 4-B
This lateral radiograph shows somewhat less comminution
than that seen in Figures 1 and 3.
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FIG. 4-C
The described operative technique was used.
FIG. 4-D
The external fixator was left in place for four weeks.
alignment of the volar fragments
(Figs. 2-M and 2-N). Screws that
lock to the plate (angular stable
screws) are very useful for complex injuries, particularly when
there is poor-quality bone.
A large radial styloid fragment can be repaired with a plate
applied to the dorsal-radial surface of the distal part of the radius between the first and second
dorsal compartments (Fig. 2-O).
With the volar and radial fragments realigned and stabilized,
the extent of the central dorsal
and metaphyseal comminution
is apparent (Fig. 2-P). While angular stable screws provide a
great deal of support to the articular surface, the surgeon should
also be prepared to apply an autogenous bone graft or a bonegraft substitute to support the
articular surface, particularly the
central fragments. In young patients, it is sometimes possible to
fill the defect with all of the loose
and displaced bone fragments
collected during the operation
(Fig. 2-Q).
Carpal injuries are repaired
prior to repair of the dorsal
fragments (Fig. 2-R). The
dorsal-ulnar fragments are then
replaced along with the dorsal
capsule, are stabilized with provisional smooth Kirschner wires,
and then are fixed with a plate
and screws (Fig. 2-S). This completes a cage, or matrix, of angular stable screws that support
the articular fragments. The
dorsal capsule is not repaired.
The wounds are closed (Fig.
2-T), and a bulky, nonconstric-
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tive dressing is applied.
Active and active-assisted
finger and forearm exercises are
initiated immediately after the
surgery. Patients treated without
external fixation wear a volar
thermoplastic wrist splint for
three to six weeks. Functional use
of the limb for light daily tasks is
encouraged. Use of external fixation and wrist splints is discontinued between three and six
weeks after the surgery, and wrist
motion exercises are begun. Re-
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CRITICAL CONCEPTS | continued
AUTHOR UPDATE:
Combined dorsal and volar plate fixation has evolved to some degree to socalled fragment-specific fixation6, but the only substantive difference is the
use of a separate plate for the radial styloid. Given the relative infrequency
of fractures that are sufficiently complex to require this treatment method,
we have limited experience with the procedure beyond the data presented
in our paper. Our recent results are similar to those in the original paper:
combined dorsal and volar plate fixation does not appear to result in devascularization of the bone fragments, major complications are uncommon,
and patients gain more motion than one might expect, given the complexity
of the fracture and the limitations of surgical reconstruction (Figs. 3-A
through 4-F).
FIG. 4-E
An anteroposterior radiograph made after implant removal demonstrates a reasonably good articular surface given the complexity of the initial articular injury.
FIG. 4-F
There is a slight dorsal tilt of the articular surface. Postoperatively, wrist flexion and extension were approximately two-thirds
of normal, and the patient had full supination and pronation.
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sistive exercises are not allowed
until radiographic signs of healing have been established.
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grants or outside funding from the AO Foundation
(D.R. and J.B.J.). None of the authors received
payments or other benefits or a commitment or
agreement to provide such benefits from a commercial entity. No commercial entity paid or
directed, or agreed to pay or direct, any benefits to
any research fund, foundation, educational institution, or other charitable or nonprofit organization
with which the authors are affiliated or associated.
David Ring, MD
Jesse B. Jupiter, MD
Department of Orthopaedic Surgery, Massachusetts General Hospital, Yawkee Center, Suite
2100, 55 Fruit Street, Boston, MA 02114. E-mail
address for D. Ring: [email protected]
Karl Prommersberger, MD
Klinik fur Handchirurgie, Salzburger Leite 1,
D97615 Bad Neustadt, Germany
In support of their research or preparation of this
manuscript, one or more of the authors received
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2. Freeland AE, Sud V, Jemison DM. Early
wrist arthrodesis for irreparable intra-articular distal radial fractures. Hand Surg.
2000;5:113-8.
3. Orbay JL, Fernandez DL. Volar fixation for
dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg [Am].
2002;27:205-15.
doi:10.2106/JBJS.E.00249
4. Henry AK. Extensile exposure. 2nd ed.
New York: Churchill Livingstone; 1973.
REFERENCES
5. Fernandez DL, Jupiter JB. Fractures of the
distal radius: a practical approach to management. New York: Springer; 1996.
1. Becton JL, Colborn GL, Goodrich JA. Use of
an internal fixator device to treat comminuted
fractures of the distal radius: report of a technique. Am J Orthop. 1998;27:619-23.
6. Swigart CR, Wolfe SW. Limited incision
open techniques for distal radius fracture
management. Orthop Clin North Am.
2001;32:317-27.
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This is an enhanced PDF from The Journal of Bone and Joint Surgery
The PDF of the article you requested follows this cover page.
Chiari Pelvic Osteotomy for Advanced Osteoarthritis in Patients with
Hip Dysplasia
Hiroshi Ito, Takeo Matsuno and Akio Minami
J Bone Joint Surg Am. 87:213-225, 2005. doi:10.2106/JBJS.E.00204
This information is current as of September 3, 2005
Reprints and Permissions
Click here to order reprints or request permission to use material from this
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The Journal of Bone and Joint Surgery
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COPYRIGHT © 2005
BY
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BONE
AND JOINT
SURGERY, INCORPORATED
Chiari Pelvic Osteotomy for
Advanced Osteoarthritis in
Patients with Hip Dysplasia
Surgical Technique
By Hiroshi Ito, MD, Takeo Matsuno, MD, and Akio Minami, MD
Investigation performed at Asahikawa Medical College, Asahikawa, Japan
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 1439-1445, July 2004
INTRODUCTION
The treatment of severe osteoarthritis due to hip
dysplasia in younger and more physically active
patients is controversial. Total hip arthroplasty in
young patients is best avoided, if possible, because
of its limited durability. The pelvic reconstructive
osteotomy is one joint-preserving procedure, the
objective of which is to provide good osseous
femoral head coverage. Chiari described a medial
displacement pelvic osteotomy for the treatment
of subluxation of the hip1. In the present report,
we describe the technique of Chiari pelvic osteotomy, performed through an Ollier lateral U
approach2,3 along with a trochanteric osteotomy,
for the treatment of advanced osteoarthritis in
dysplastic hips.
SURGICAL TECHNIQUE
The patient is placed in the lateral decubitus position with the extremity draped free on the table.
No traction table or any other distraction device is
used. Intraoperative fluoroscopy or radiography is
used to confirm the appropriate osteotomy line.
The skin incision (Fig. 1) begins at the anterior superior iliac spine and is curved downward and
posteriorly for a distance of 2 cm, distal to the base
of the greater trochanter, and then is curved up-
ABSTRACT
BACKGROUND:
It is not clear whether a Chiari pelvic osteotomy performed for the treatment of advanced osteoarthritis
can delay the need for total hip arthroplasty. We
present the mid-term results of the Chiari pelvic osteotomy performed for the treatment of Tönnis grade-3
osteoarthritis (large cysts, severe narrowing of the
joint space, or severe deformity or necrosis of the
head with extensive osteophyte formation), with a particular focus on whether this procedure can delay the
need for total hip arthroplasty.
METHODS:
We followed thirty-two hips in thirty-one patients with
Tönnis grade-3 osteoarthritis who had refused total hip
arthroplasty and had been treated with a Chiari pelvic
osteotomy. The mean age at the time of surgery was
35.2 years. The mean duration of follow-up was 11.2
years, at which time clinical evaluation with the Harris
hip score and radiographic evaluation were performed.
RESULTS:
The average Harris hip score improved from 52 points
preoperatively to 77 points at the time of follow-up; the
average pain score improved from 20 to 31 points.
Three hips with a hip score of <70 points required total
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ABSTRACT | continued
hip arthroplasty. With a hip score of <70 points as the end point, the cumulative rate of survival at ten years was 72%.
The clinical outcome was significantly influenced by the preoperative center-edge angle (p = 0.004), the preoperative
acetabular head index (p = 0.039), achievement of the appropriate osteotomy level (p = 0.011), and superior migration
(p = 0.009) and lateral migration (p = 0.026) of the femoral head.
continued
FIG. 1
The skin incision of the Ollier lateral U approach to the hip joint.
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FIG. 2
The anterior dissection is carried out by separating the tensor fasciae latae anteriorly and the gluteus medius posteriorly, continuing distally to the greater trochanter.
ward and back to the posterior
superior iliac spine. The exposure is developed by incising the
gluteal fascia in the same line on
the skin incision. The anterior
interval (Fig. 2) between the
tensor fasciae latae and the gluteus medius is identified and
dissection is carried out by separating the tensor fascia latae anteriorly and the gluteus medius
ABSTRACT | continued
CONCLUSIONS:
Although the clinical results were inferior to those of total hip arthroplasty,
Chiari pelvic osteotomy may be an option for young patients with advanced
osteoarthritis who prefer a joint-conserving procedure to total hip arthroplasty and accept a clinical outcome that is predicted to be less optimal than
that of total hip arthroplasty. Moderate dysplasia and moderate subluxation
without complete obliteration of the joint space and a preoperative centeredge angle of at least 10° are desirable selection criteria.
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FIG. 3
The posterior dissection is carried out by blunt splitting of the fibers of the gluteus maximus.
posteriorly, continuing distally
to the greater trochanter. Blood
vessels in this interval are coagulated. A posterior dissection is
carried out by blunt digital
splitting of the fibers of the gluteus maximus at the level of the
underlying posterior border of
the gluteus medius muscle
(Fig. 3). The short external
rotator muscles are identified
with the hip placed in internal
rotation. The piriformis, obturator internus, and gemelli are
incised at their insertions, and
then the anterior and posterior
borders of the gluteus medius
with the underlying gluteus
minimus can be clearly visualized with and defined by the
periosteal elevators placed beneath them (Fig. 4). After the
osteotomy line is marked, the
greater trochanter is osteotomized obliquely at its base, with
care being taken to avoid injury
to the femoral neck and to pre-
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FIG. 4
The anterior and posterior borders of the gluteus medius with the underlying gluteus minimus are clearly visualized with and defined by the
periosteal elevators placed beneath them.
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FIG. 5
The greater trochanter with its tendinous insertion of the gluteus medius and minimus is retracted proximally to expose the lateral surface
of the ilium.
serve the insertion of the gluteus medius and minimus
muscles. The greater trochanter
with its tendinous insertion is
then retracted proximally to
expose the entire joint capsule
(Fig. 5). The reflected head
of the rectus femoris is then
incised at its insertion. The
lateral surface of the ilium extending from the anterior inferior iliac spine to the greater
sciatic notch as well as the entire superior joint capsule is
exposed with use of several
Steinmann pins (Fig. 5).
With use of fluoroscopy, a
2-mm-diameter Kirschner wire
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is inserted just tangential to the
superior joint capsule as a guide
for the osteotomy (Fig. 6). The
dome-shaped osteotomy line is
then drawn with use of electrocautery (Fig. 7). This line should
run just proximal to the capsular attachments. The angle of inclination for the osteotomy line
should be 10° or 20° upward in
relation to the transverse plane
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of the body. The dome-shaped
osteotomy is performed with
use of a reciprocating power saw
(Fig. 8). After the osteotomy is
completed, the distal osseous
fragment is manually displaced
medially and slightly posteriorly to improve lateral and anterior femoral head coverage
(Fig. 9). Two 2-mm-diameter
Kirschner wires are then in-
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CRITICAL CONCEPTS
INDICATIONS:
The performance of a Chiari pelvic osteotomy for the treatment
of advanced osteoarthritis due
to hip dysplasia should be limited to patients with an age of
less than fifty years who refuse
total hip arthroplasty after having received preoperative information that a future revision
arthroplasty is likely and who accept a clinical outcome that is
predicted to be less favorable
than that of total hip arthroplasty. The patient should also
understand that clinical functional improvement requires several months after surgery.
CONTRAINDICATIONS:
Radiographic evidence of severe
dysplasia and subluxation with a
preoperative center-edge angle of
less than -10° or complete obliteration of the joint space are contraindications to this procedure.
Patients who are unwilling to accept a clinical outcome that is
inferior to that of total hip arthroplasty also are not candidates for
this procedure.
PITFALLS:
FIG. 6
A 2-mm-diameter Kirschner wire is inserted just tangential to the superior joint capsule
as a guide for the osteotomy.
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The osteotomy level is one of
the important factors influencing
the outcome. The level of the osteotomy is considered to be appropriate when placed between
0 and 10 mm from the superior
osseous margin of the acetabulum4. Intraoperative use of
fluoroscopy or radiographs is
recommended. Chiari emphasized that the risks of the osteotomy are more pronounced
when it is performed at too low a
level because the proximal osteotomized fragment presses excessively on the joint capsule,
continued
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CRITICAL CONCEPTS | continued
resulting in a poor outcome1. Efforts should be made to avoid an excessively low or high osteotomy.
Sufficient displacement of the fragment for the improvement in femoral head coverage is technically important. This also
provides good acetabular bone stock for subsequent total hip arthroplasty. A postoperative center-edge angle of 30° to 35°,
which usually requires 1.5 to 2.5 cm of medial displacement of the distal fragment, is ideal for femoral head coverage.
If the preoperative position of the greater trochanter is high-riding, distal advancement of the trochanter to an anatomically normal position is performed. Ideally, the proximal end of the greater trochanter should be at the same level as the
center of the femoral head.
Preoperative education of the patient regarding the possibility of limited functional improvement is necessary.
continued
FIG. 7
The dome-shaped osteotomy line is drawn.
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FIG. 8
The dome-shaped osteotomy is performed with use of a reciprocating power saw.
serted from the proximal part of
the ilium into the ischium distally to fix the fragment in position. Two or three cancellous
screws are then inserted to reattach the osteotomized greater
trochanter (Fig. 10). The greater
trochanter is advanced distally
by 1 to 2.5 cm if it is high-riding
preoperatively. In hips in which
a femoral valgus osteotomy is
performed simultaneously, a cable system is used for fixation of
the greater trochanter. A final
check of the improvement of
femoral head coverage and the
appropriate position of the
greater trochanter is performed
fluoroscopically. The reflected
head of the rectus femoris is
sutured to the straight head.
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One 3-mm suction drain is inserted, and the wound is closed
in layers.
A femoral valgus osteotomy is performed if the femoral
head is distorted and preoperative radiographs show good
congruity between the femoral
head and the acetabulum with
the hip in an adducted position.
The femoral osteotomy is per-
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formed through a lateral approach in which the incision is
enlarged by adding a distal extension from the base of the
greater trochanter, parallel to
the femur, for a distance of 6 to
8 cm. The femoral shaft is exposed by detaching the vastus
lateralis, and the osteotomy cut
is performed with a power saw.
A laterally based triangular
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wedge is removed, and a 110° to
130°-angle plate is used for
fixation (Fig. 11).
Postoperative traction or
cast immobilization is not
used. After two weeks of bed
rest, the patient is allowed to
use a wheelchair, and nonweight-bearing walking is allowed as tolerated. Partial
weight-bearing is begun four
FIG. 9
Displacement of the distal fragment is performed by pushing it medially and slightly posteriorly.
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FIG. 10
Two 2-mm-diameter Kirschner wires are inserted from the proximal part of the ilium into the distal part of the ischium. Two or three cancellous screws are used to reattach the osteotomized greater trochanter.
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FIG. 11
Femoral valgus osteotomy. A laterally based triangular wedge is removed, and a 110° to 130°-angle plate is used for fixation.
CRITICAL CONCEPTS | continued
AUTHOR UPDATE:
In the original study, the osteotomized greater trochanter was reattached with use of two or three metallic screws. Since
January 2004, we have used bioresorbable cancellous screws made of forged composites of hydroxyapatite particles and
polylactic acid (Super-Fixsorb; Takiron, Osaka, Japan)5. Bioabsorbable screws offer several advantages compared with
metallic screws. There is no need to remove the implant, problems associated with migration of the screws can be
avoided, and gradual stress transfer to the bone may permit more complete bone-remodeling. However, poly-L-lactide
screws carry a risk of fracture when used to reattach the osteotomized greater trochanter6. These screws have a threaded
diameter of 6.5 mm, a core diameter of 4.0 mm, an unthreaded diameter of 4.5 mm, and a length of 35 to 70 mm. A
screw-hole is made to penetrate the medial femoral cortex with use of a 4.4-mm-diameter drill-bit and is tapped to a
threaded diameter of 6.6 mm. The screw is inserted with use of a screwdriver so that it penetrates the medial cortex. All
screws have been inserted with a washer to increase interfragmental compression. Three screws are routinely used. Thus
far, good bone union has been obtained within three to six months postoperatively in all hips without displacement of the
greater trochanteric fragment.
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to six weeks after surgery when
a pelvic osteotomy alone has
been performed and at eight
weeks when combined pelvic
and femoral osteotomies have
been performed. Full weightbearing is started ten to twelve
weeks postoperatively. The
two Kirschner wires are removed six weeks postoperatively with the patient under
local anesthesia.
Hiroshi Ito, MD
Takeo Matsuno, MD
Department of Orthopaedic Surgery, Asahikawa
Medical College, Midorigaoka Higashi 2-1-1-1,
Asahikawa 078-8510, Japan. E-mail address for H.
Ito: [email protected]
S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 ·
Akio Minami, MD
Department of Orthopaedic Surgery, Hokkaido
University School of Medicine, Kita-ku Kita-15
Nishi-7, Sapporo 060-8638, Japan
The authors did not receive grants or outside funding in support of their research or preparation of
this manuscript. They did not receive payments or
other benefits or a commitment or agreement to
provide such benefits from a commercial entity.
No commercial entity paid or directed, or agreed
to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
The line drawings in this article are the work of
Jennifer Fairman ([email protected]).
doi:10.2106/JBJS.E.00204
REFERENCES
1. Chiari K. Medial displacement osteotomy
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of the pelvis. Clin Orthop Relat Res. 1974;
98:55-71.
2. Bost FC, Schottstaedt ER, Larsen LJ. Surgical approaches to the hip joint. Instr Course
Lect. 1954;11:131-42.
3. Katayama R, Katayama K. [Arthroplasty in
Katayama’s operation orthopaedics.] 8th ed.
Tokyo: Nankodo; 1982. Hip joint; p 195-207.
Japanese.
4. Matsuno T, Ichioka Y, Kaneda K. Modified
Chiari pelvic osteotomy: a long-term follow-up
study. J Bone Joint Surg Am. 1992;74:470-8.
5. Shikinami Y, Okuno M. Bioresorbable devices made of forged composites of hydroxyapatite (HA) particles and poly-L-lactide (PLLA):
part I. Basic characteristics. Biomaterials.
1999;20:859-77.
6. Ito H, Minami A, Tanino H, Matsuno T. Fixation with poly-L-lactic acid screws in hip osteotomy: 68 hips followed for 18-46 months.
Acta Orthop Scand. 2002;73:60-4.
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Partial Epiphyseal Preservation and Intercalary Allograft
Reconstruction in High-Grade Metaphyseal Osteosarcoma of the Knee
D. Luis Muscolo, Miguel A. Ayerza, Luis A. Aponte-Tinao and Maximiliano Ranalletta
J Bone Joint Surg Am. 87:226-236, 2005. doi:10.2106/JBJS.E.00253
This information is current as of September 3, 2005
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BONE
AND JOINT
SURGERY, INCORPORATED
Partial Epiphyseal
Preservation and Intercalary
Allograft Reconstruction in
High-Grade Metaphyseal
Osteosarcoma of the Knee
Surgical Technique
By D. Luis Muscolo, MD, Miguel A. Ayerza, MD, Luis A. Aponte-Tinao, MD, and Maximiliano Ranalletta, MD
Investigation performed at the Institute of Orthopedics “Carlos E. Ottolenghi,” Italian Hospital of Buenos Aires, Buenos Aires, Argentina
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 2686-2693, December 2004
ABSTRACT
BACKGROUND:
The purpose of this study was to analyze a series of patients with a high-grade metaphyseal osteosarcoma of
the knee who had been treated with a transepiphyseal
resection, with preservation of the distal femoral and
the proximal tibial (articular) portions of the epiphysis,
and an intercalary allograft reconstruction.
METHODS:
The cases of thirteen patients with a high-grade metaphyseal osteosarcoma around the knee who had
transepiphyseal resection and reconstruction with
an intercalary allograft were retrospectively reviewed
at a mean of sixty-three months. Complications, disease-free survival of the patient, final preservation
of the limb and epiphysis, and functional results according to the Musculoskeletal Tumor Society scoring
system were documented at the time of the latest
follow-up.
continued
INTRODUCTION
The survival rate of patients with a high-grade osteosarcoma that is diagnosed in a timely manner
and treated with modern chemotherapy regimens
and proper surgical margins can be >70% after five
years1-3. Most surgical techniques that are presently
used to treat high-grade metaphyseal osteosarcomas around the knee include resection of one or
both epiphyses. Recent evidence has suggested that
presently used imaging techniques, particularly
magnetic resonance imaging, can safely and accurately define tumor limits in patients who have a
metaphyseal osteosarcoma growing toward the epiphysis in the knee joint. In the present report, we
describe the technical details of the transepiphyseal
resection and intercalary allograft reconstruction,
with preservation of both epiphyses, in patients
with a high-grade osteosarcoma of the knee.
SURGICAL TECHNIQUE
Partial Epiphyseal Preservation of the
Distal Part of the Femur
Patients are managed with chemotherapy and, after
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FIG. 1
Coronal T1-weighted
magnetic resonance
image showing the
preoperative extent of
the femoral tumor.
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the induction period, definitive
surgical treatment of the primary
lesion is performed. Magnetic
resonance images are acquired
with a 1.5-T Magnetom Vision
unit (Siemens, Erlangen, Germany) at the time of the diagnosis and after chemotherapy in
order to evaluate the tumor response (Fig. 1). All operations
are performed in a clean-air enclosure with vertical airflow and
usually with spinal anesthesia.
The patient is placed on the operating table in the supine position. A sandbag is placed under
the ipsilateral buttock. A long
midline incision is made, beginning in the middle part of the
thigh, and a medial parapatellar
arthrotomy is performed to en-
FIG. 2
Intraoperative photograph illustrating how the posterior and medial structures are protected and retracted prior to the performance of the
osteotomy.
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ABSTRACT | continued
RESULTS:
At the final follow-up examination,
eleven of the thirteen patients
continued to be disease-free.
One patient died of bone and
pulmonary metastases with no
evidence of local recurrence,
and the remaining patient had
no evidence of disease after resection of a local recurrence of
the tumor in the soft tissues. No
patient had a local recurrence in
the remaining epiphysis. Seven
patients had complications that
included a fracture (three patients), diaphyseal nonunion
(two), deep infection (one), and
a local recurrence in the soft tissues (one). The allograft was removed in only four of these
patients. At the latest follow-up
examination, twelve patients
were alive with preserved limbs.
In one patient, the epiphysis,
which originally had been preserved, was resected because
of a metaphyseal fracture, and
the limb was reconstructed with
an osteoarticular allograft. The
patients with a preserved epiphysis had an average functional
score of 27 points (maximum,
30 points).
S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 ·
able a wide exposure of the distal
part of the femur and the knee
joint. The biopsy track is left in
continuity with the specimen.
The distal part of the femur is
approached through the interval
between the rectus femoris and
the vastus medialis. If there is an
extraosseous tumor component,
a cuff of normal muscle must be
excised. Proximal femoral osteotomy is performed at the appropriate location as determined on
the basis of the preoperative im-
JBJS . ORG
aging studies. All remaining soft
tissues at the level of the transection are cleared. After the posterior and medial structures have
been protected and retracted
(Fig. 2), the osteotomy is performed perpendicular to the
long axis of the femur.
Following the osteotomy,
the distal part of the femur is
pulled forward in order to expose
the soft-tissue attachments of the
popliteal space (Fig. 3). The
popliteal artery is mobilized, and
CONCLUSIONS:
Preservation of the epiphysis in
high-grade metaphyseal osteosarcoma at the knee is an alternative in carefully selected
patients. Crucial factors needed
to obtain local tumor control and
achieve an acceptable functional
result are a positive response to
chemotherapy, accurate preoperative assessment of tumor extension to the epiphysis, and
appropriate fixation techniques
for intercalary allografts.
FIG. 3
Intraoperative photograph illustrating how the distal part of the femur is pulled forward in
order to expose the soft-tissue attachments of the popliteal space following the diaphyseal osteotomy. Note that both heads of the gastrocnemius have been released and the
posterior capsule has been opened.
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FIG. 4
Intraoperative photograph made after the intraepiphyseal osteotomy site has been marked. The cruciate and collateral ligaments have
been identified and remain intact and attached to the epiphysis that is saved. Partial disruption of cruciate ligament insertions might be
necessary when the osteotomy is performed very close to the joint.
FIG. 5
Intraoperative photograph made after the donor graft has been thawed and cut to the proper length to fit the bone defect.
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FIG. 6
Intraoperative photograph illustrating how the osteotomy site is stabilized by means of internal fixation with cancellous screws compressing the metaphyseal bone.
FIG. 7
Intraoperative photograph made after the placement of a condylar buttress plate to fix the diaphyseal osteotomy site. In order to minimize
the risk of fracture, the plate covers the entire length of the allograft.
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the geniculate vessels are ligated
and transected. Both heads of the
gastrocnemius are released, and
the posterior capsule is opened.
The cruciate and collateral ligaments are identified and are left
intact and attached to the epiphysis that is saved. The next step
is to mark the intraepiphyseal
site (Fig. 4). The osteotomy is
planned 1 to 2 cm from the distal
edge of tumor growth, defined
S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 ·
as the point at which the marrow signal intensity changes
from abnormal to normal. At the
time of surgery, measurements
on preoperative magnetic resonance imaging are correlated
with anatomical landmarks
(the epicondyles, the intercondylar notch roof, and the extent
of the femoral articular cartilage). Following the osteotomy,
the distal part of the femur is
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CRITICAL CONCEPTS
INDICATIONS:
• Tumors with no evidence of
progression clinically or on
magnetic resonance imaging
studies during chemotherapy
• A residual epiphysis of at least
1 cm in thickness should be
available in order to allow for
the fixation of the osteotomy
junction and the achievement
of safe oncologic margins
CONTRAINDICATIONS:
• Tumor progression during
chemotherapy
• Patients in whom preoperative
imaging studies demonstrate
evidence of epiphyseal compromise
• Very young patients (patients
less than eight years old)
who are predicted to have a
substantial final limb-length
discrepancy
continued
FIG. 8
Anteroposterior and lateral radiographs, made ten months after tumor resection and intercalary allografting of the distal part of the femur, showing healing of both osteotomy
sites.
passed off the operative field.
After the tumor has been resected, an allograft segment that
has been tailored to fit the bone
defect is inserted. Fresh-frozen
allografts are obtained and
stored according to a technique
that has been described
previously4. The allograft is selected on the basis of a comparison of the radiographs of the
patient with those of the donor.
After the donor bone is thawed
in a warm solution, it is cut to
the proper length (Fig. 5). The
intraepiphyseal osteotomy site is
temporarily secured with
threaded Kirschner wires that are
inserted through the distal parts
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CRITICAL CONCEPTS | continued
PITFALLS:
• It is important to have stringent preoperative criteria for
selecting patients who are suitable for this technique
• The procedure is best performed by an orthopaedic
oncologic surgeon with experience in knee reconstructive
surgery and sports-medicine
surgery
• All previous biopsy sites and
all potentially contaminated
tissues, including any needle
biopsy tracks, should be removed en bloc
• The major neurovascular bundle must be free of tumor
• Intraoperative guidelines or
parameters for epiphyseal
osteotomies are based on
measurements made on preoperative magnetic resonance
imaging studies
FIG. 9
Sagittal T1-weighted magnetic resonance image showing the preoperative extent of the
tibial tumor.
• In order to avoid allograft fracture, the internal fixation device should cover the entire
length of the graft
• In tibial reconstructions, it is
important to stabilize the proximal tibiofibular joint and to use
a medial gastrocnemius rotation flap to cover the allograft
continued
of both condyles and into the allograft. Then, the osteotomy site
is stabilized by means of internal
fixation with cancellous screws
compressing the metaphyseal
bone (Fig. 6). Before the proximal osteotomy site is stabilized,
the posterior capsule is repaired
by suturing autologous capsular
tissues to the capsular tissues
provided by the allograft. A
condylar buttress plate is placed
to fix the diaphyseal osteotomy
site. In order to minimize the risk
of fracture, the plate should
cover the entire length of the allograft (Fig. 7).
Two suction drains are inserted and, after lavage of the
wound with saline solution, a
meticulous suture repair of the
quadriceps is required. A layered
closure of the subcutaneous tissues and skin is then performed.
Antibiotics are given intravenously according to the usual
prophylactic protocol, and routine anticoagulation therapy is
not used. External splinting with
a brace with the knee in full ex-
tension is used until the wound
has healed.
After two days, the drains are
removed and the wound is inspected. Passive range-of-motion
exercises are begun at two weeks
after the operation. The patient is
allowed partial weight-bearing at
eight to twelve weeks (Fig. 8).
Partial Epiphyseal Preservation
of the Proximal Part of the Tibia
The same basic principles are applied when an intraepiphyseal resection of the proximal part of
the tibia is performed (Fig. 9). A
long midline incision is made,
beginning at the proximal part of
the patella and extending over
the tibia. A medial parapatellar
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FIG. 10
Intraoperative photograph made after the osteotomy, illustrating how the proximal part of the tibia is pulled forward in order to expose the
soft-tissue attachments of the popliteal space.
FIG. 11
Intraoperative photograph showing the performance of the intraepiphyseal osteotomy according to the preoperative guidelines.
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FIG. 12
Intraoperative photograph showing the bone defect after resection of the tumor. Note that both menisci, the medial
collateral ligament, and the cruciate ligaments are identified and remain attached to the epiphysis that is saved.
FIG. 13
Intraoperative photograph made after both osteotomy sites
were stabilized by means of internal fixation with cancellous
screws and a plate in order to minimize the risk of fracture.
arthrotomy is performed to enable a wide exposure of the proximal part of the tibia and the
knee joint. The biopsy track is
left in continuity with the specimen. The proximal part of the
tibia is exposed extraperiosteally
and, if there is an extraosseous
tumor component, a cuff of normal muscle must be excised. The
proximal tibiofibular joint is
opened completely. A distal tibial osteotomy is planned at the
appropriate location as determined on the basis of the preoperative imaging studies. All
remaining soft tissues at the level
of the transection are cleared. After the posterior and lateral
structures have been protected
and retracted, the osteotomy is
performed perpendicular to the
long axis of the tibia.
Following the osteotomy,
the proximal part of the tibia is
pulled forward in order to expose the soft-tissue attachments
of the popliteal space (Fig. 10).
Both menisci, the medial collateral ligament, and both cruciate
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ligaments are identified and are
left intact around the epiphysis
that is saved. The next step is to
mark the intraepiphyseal osteotomy site. The osteotomy is
planned 1 to 2 cm from the
proximal edge of tumor growth,
defined as the point at which the
marrow signal intensity changes
from abnormal to normal (Fig.
11). At the time of surgery,
measurements on preoperative
magnetic resonance images are
correlated with anatomical landmarks (the tibial plateau surface, the proximal end of the
fibula, and the patellar tendon
S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 ·
insertion on the tibia). Following the osteotomy, the proximal
part of the tibia is passed off the
operative field.
After the tumor has been resected (Fig. 12), an allograft segment that has been tailored to fit
the bone defect is inserted. After
the donor bone is thawed in a
warm solution, it is cut to the
proper length. The intraepiphyseal osteotomy site is temporarily
secured with threaded Kirschner
wires that are inserted through
the proximal part of the tibial
plateau and into the allograft.
Then, the osteotomy site is stabi-
FIG. 14
Intraoperative photograph made after reconstruction of the extensor mechanism by suturing the allograft patellar tendon to the corresponding host patellar tendon.
JBJS . ORG
CRITICAL CONCEPTS | continued
AUTHOR UPDATE:
Since the original article was
published, the surgical approach
has remained basically unchanged. However, in order to
achieve the closest possible anatomical match, the selection of
the allograft is now performed
on the basis of a comparison of
the allograft computerized tomographic scans that are available
at our bone bank with those of
the patient and not on the basis
of radiographs, as was done previously. In the original article,
the diaphyseal osteotomy sites
in some patients were fixed with
intramedullary rods; currently,
these devices are not used because they were associated with
a higher nonunion rate. Plate fixation is now used for the majority of our patients because we
believe that it imparts greater
mechanical stability to the reconstruction. The postoperative
care and rehabilitation have remained unchanged. At the
present time, twenty-three patients with high-grade osteosarcoma around the knee have
been managed with this technique involving partial epiphyseal preservation, with no
instances of recurrence in the
retained epiphysis.
lized by means of internal fixation with cancellous screws
compressing the metaphyseal
bone. The proximal part of the
fibula at the tibiofibular joint is
fixed to the proximal part of the
tibia with a cancellous screw. A
plate is applied to fix the diaphyseal osteotomy site. In order to
minimize the risk of fracture, the
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JBJS . ORG
a brace with the knee in full extension is used until the wound
has healed.
After two days, the drains
are removed and the wound is
inspected. Passive range-ofmotion exercises are begun at
two weeks after the operation.
The patient is allowed partial
weight-bearing at eight to twelve
weeks (Fig. 15).
D. Luis Muscolo, MD
Miguel A. Ayerza, MD
Luis A. Aponte-Tinao, MD
Maximiliano Ranalletta, MD
Institute of Orthopedics “Carlos E. Ottolenghi,”
Italian Hospital of Buenos Aires, Potosí
4215, (1199) Buenos Aires, Argentina.
E-mail address for D.L. Muscolo:
[email protected]
The authors did not receive grants or outside funding in support of their research or preparation of
this manuscript. They did not receive payments or
other benefits or a commitment or agreement to
provide such benefits from a commercial entity.
No commercial entity paid or directed, or agreed
to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
FIG. 15
Anteroposterior and lateral radiographs, made fifteen months after tumor resection and
intercalary allografting of the proximal part of the tibia, showing healing of both osteotomy sites.
plate should cover the entire
length of the allograft (Fig. 13).
The extensor mechanism is
then reconstructed by attachment of the allograft patellar
tendon to the corresponding
host patellar tendon (Fig. 14).
The donor patellar tendon is
transected 2 cm from its insertion on the patella and is sectioned longitudinally. The two
flaps created by the longitudinal
sectioning of the donor tendon
are applied over the host patellar
tendon and are sutured to it to
restore the extensor mechanism.
Finally, a medial gastrocnemius
transposition flap is created to
provide soft-tissue coverage of
the proximal tibial allograft.
Two suction drains are inserted, and, after lavage of the
wound with saline solution, layered closure of the subcutaneous
tissues and skin is performed.
Antibiotics are given intravenously according to the usual
prophylactic protocol, and routine anticoagulation therapy is
not used. External splinting with
doi:10.2106/JBJS.E.00253
REFERENCES
1. Bacci G, Ferrari S, Lari S, Mercuri M, Donati D, Longhi A, Forni C, Bertoni F, Versari M,
Pignotti E. Osteosarcoma of the limb. Amputation or limb salvage in patients treated by
neoadjuvant chemotherapy. J Bone Joint Surg
Br. 2002;84:88-92.
2. Sluga M, Windhager R, Lang S, Heinzl H,
Bielack S, Kotz R. Local and systemic control
after ablative and limb sparing surgery in patients with osteosarcoma. Clin Orthop Relat
Res. 1999;358:120-7.
3. Thompson RC Jr, Cheng EY, Clohisy DR,
Perentesis J, Manivel C, Le CT. Results of
treatment for metastatic osteosarcoma with
neoadjuvant chemotherapy and surgery. Clin
Orthop Relat Res. 2002;397:240-7.
4. Ottolenghi CE, Muscolo DL, Maenza R.
Bone defect reconstruction by massive allograft: technique and results of 51 cases followed for 5 to 32 years. In: Straub LR, Wilson
PD Jr, editors. Clinical trends in orthopedics.
New York: Thieme-Stratton; 1982. p 171-83.
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Vascularized Proximal Fibular Epiphyseal Transfer for Distal Radial
Reconstruction
Marco Innocenti, Luca Delcroix, Marco Manfrini, Massimo Ceruso and Rodolfo Capanna
J Bone Joint Surg Am. 87:237-246, 2005. doi:10.2106/JBJS.E.00295
This information is current as of September 3, 2005
Reprints and Permissions
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www.jbjs.org
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COPYRIGHT © 2005
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THE JOURNAL
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BONE
AND JOINT
SURGERY, INCORPORATED
Vascularized Proximal
Fibular Epiphyseal
Transfer for Distal
Radial Reconstruction
Surgical Technique
By Marco Innocenti, MD, Luca Delcroix, MD, Marco Manfrini, MD, Massimo Ceruso, MD,
and Rodolfo Capanna, MD
Investigation performed at Azienda Ospedaliera Careggi, Florence, and Istituto Ortopedico Rizzoli, Bologna, Italy
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 1504-1511, July 2004
INTRODUCTION
Epiphyseal reconstruction of long bones in children is a challenging issue in orthopaedics. The double goal of restoring joint function and
growth potential cannot be achieved by means of conventional procedures such as insertion of a prosthesis or a nonvascularized allograft. A
vascularized autograft consisting of the proximal fibular epiphysis and
a variable amount of the proximal diaphysis is an effective biological
alternative in the reconstruction of the distal aspect of the radius and
the proximal part of the humerus in children1,2. The purpose of this report is to describe the technical details of this procedure.
SURGICAL TECHNIQUE
Harvesting of the Proximal Part of the Fibula
The aim of this procedure is the harvest of the proximal epiphysis
and a variable amount of the diaphysis of the fibula with use of the
anterior tibial artery and veins as a vascular pedicle3,4. This artery
(Fig. 1) supplies the epiphysis by means of a recurrent epiphyseal
branch as well as the proximal two-thirds of the diaphysis by means
of tiny musculoperiosteal branches, which must be carefully preserved during the dissection. During the surgical exposure of the
fibula, great care also should be taken to prevent damage to the
motor branches of the peroneal nerve and to the epiphyseal vascular
pedicle.
Because of its anatomical similarities with the distal part of the
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ABSTRACT
BACKGROUND:
Treatment of the loss of the distal part of the radius, including
the physis and epiphysis, in a
skeletally immature patient requires both replacement of the
osseous defect and restoration
of longitudinal growth. Autologous vascularized epiphyseal
transfer is the only possible procedure that can meet both
requirements.
METHODS:
Between 1993 and 2002, six
patients with a mean age of 8.4
years (range, six to eleven
years) who had a malignant
bone tumor in the distal part of
the radius underwent microsurgical reconstruction of the distal
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ABSTRACT | continued
Fig. 1 The anterior tibial artery is able to supply the proximal fibular epiphysis as well
as the proximal two-thirds of
the diaphysis.
part of the radius with a vascularized proximal fibular transfer,
including the physis and a variable length of the diaphysis. All
of the grafts were supplied by
the anterior tibial vascular network. The rate of survival and
bone union of the graft, the
growth rate per year, the ratio
between the lengths of the ulna
and the reconstructed radius,
and the range of motion of the
wrist were evaluated for five of
the six patients who had been
followed for three years or more.
Figs. 2-A, 2-B, and 2-C Anterolateral approach for harvesting the proximal part of the
fibula. Figs. 2-A and 2-B The
skin incision is anterolateral
and parallel to the lateral
edge of the tibialis anterior
muscle.
RESULTS:
The mean duration of follow-up
of the six patients was 4.4 years
(range, eight months to nine
years). All six transfers survived
and united with the host bone
within two months postoperatively. The five patients who were
followed for three years or more
had consistent and predictable
longitudinal growth. Serial radiographs revealed remodeling of
the articular surface. The functional result was rated as excellent for all but one patient, in
whom the distal part of the ulna
had also been resected because
of neoplastic involvement. No
major complication occurred at
the recipient site, whereas a
peroneal nerve palsy occurred at
the donor site in three patients.
The palsy was transient in two
patients, but it persisted in one.
No instability of the knee joint
was observed.
FIG. 1
continued
radius, the proximal part of the
contralateral fibula is preferred
for reconstruction following distal radial loss. The patient is
FIG. 2-A
FIG. 2-B
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ABSTRACT | continued
CONCLUSIONS:
After radical resection of the distal part of the radius because of
a neoplasm in children, vascularized proximal fibular transfer,
based on the anterior tibial artery, permits a one-stage skeletal and joint reconstruction,
provides excellent function, and
minimizes the discrepancy between the distal radial and ulnar
lengths.
placed on the operating table in
the supine position. The hip and
the knee of the selected donor
extremity are flexed, and a steril-
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ized tourniquet is applied. Since
the dissection can be difficult
and time-consuming, the tourniquet should be inflated at the
last minute in order to take full
advantage of the ischemia time,
which should not exceed two
hours.
An anterolateral approach
is used to isolate the proximal
part of the fibula on the basis of
the anterior tibial arterial network (Figs. 2-A, 2-B, and 2-C).
The dissection is carried out in
the intermuscular plane between the tibialis anterior and
the extensor digitorum longus
muscles (Fig. 2-C). The neurovascular bundle is better ex-
FIG. 2-C
The deep dissection is carried out in the interval between the tibialis anterior and the extensor digitorum longus muscles.
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CRITICAL CONCEPTS
INDICATIONS:
A vascularized transfer of the
proximal fibular epiphysis is indicated in the reconstruction of the
proximal part of the humerus and
the distal aspect of the radius in
children. The procedure is appropriate for the treatment of a tumor, congenital deformity, or
traumatic injury. The longer the
expected period of time between
surgery and the end of growth,
the stronger is the indication for
this technique, which can provide
substantial longitudinal growth.
The anatomical similarities between the proximal aspect of the
fibula and the distal aspect of
the radius make this procedure
particularly useful in the reconstruction of this segment, especially when taking into account
the severe functional impairment that can result from the
length discrepancy with the adjacent ulna with other reconstructive options.
CONTRAINDICATIONS:
Anatomical variations of the vascular network of the leg represent the major contraindication
for this technique. Preoperative
angiography (Fig. 9) provides
crucial information regarding the
epiphyseal vascular supply and
is able to demonstrate the recurrent branch of the anterior tibial
artery and its contribution to the
blood supply of the proximal fibular epiphysis. With the absence
and/or hypoplasia of this
branch, the procedure cannot be
performed. In addition, the anterior tibial artery cannot be harvested as the vascular pedicle
of such a graft in patients in
whom this artery is the dominant vascular supply to the foot.
continued
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FIG. 3-A
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FIG. 3-B
Figs. 3-A, 3-B, and 3-C Dissection of the neurovascular
bundle. Fig. 3-A In the distal part of the leg, only occasional motor branches of the peroneal nerve surround
the anterior tibial vascular pedicle, and its dissection is
quite easy at this level. Fig. 3-B Much more tedious is
the dissection proximally, where many motor branches
(arrows) cross the vessels on the way to the muscles of
the anterior compartment. Fig. 3-C In this patient, a motor branch (arrow) is located between the recurrent epiphyseal branch of the anterior tibial artery and the fibula.
In order to harvest the bone, this branch must be divided
and subsequently repaired.
FIG. 3-C
posed from distal to proximal,
since the dissection of the peroneal nerve from the anterior
tibial artery and veins is easier
in the distal portion of the operating field (Fig. 3-A). In the
proximal one-half of the leg, the
nerve surrounds the vascular
bundle in an intricate threedimensional pattern and sends
many branches to the muscles
of the anterior compartment
(Fig. 3-B). Some of these motor
branches may perforate the
space between the vascular bundle and the bone and therefore
cannot be dissected (Fig. 3-C).
In this case, the motor branch
is divided and then repaired
with use of microsurgical
techniques.
In order to expose the fibula, the extensor digitorum longus muscle, together with the
peroneus longus muscle, is
sharply detached from its proximal insertion at the level of the
emergence of the peroneal nerve
into the anterior compartment of
the leg (Figs. 4-A, 4-B, and 4-C).
The proximal muscular cuff
must be left attached to the fibular head since it contains the recurrent epiphyseal branch of the
anterior tibial artery on which
this transfer is based. During the
diaphyseal dissection, as many
periosteal branches as possible
are preserved. For this reason, it
is recommended that the interosseous membrane and a longitudinal strip of muscle be
harvested as well in order to protect the small branches from the
main artery to the diaphyseal periosteum of the proximal part of
the fibula.
The fibula is resected and is
separated from the surrounding
muscles and the peroneal artery, which is located in close
proximity to the posteromedial
aspect of the middle and distal
parts of the fibula. An extra
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FIG. 4-C
FIG. 4-A
Figs. 4-A, 4-B, and 4-C Transection of
the extensor digitorum longus (E.D.L.)
and peroneus longus (P.L.) muscles
should be done at the level of the fibular neck. The peroneal nerve acts as a
landmark, and the muscle cuff proximal to it should be left intact in order
to prevent damage to the epiphyseal
artery. (TA = tibialis anterior muscle.)
FIG. 4-B
portion of periosteum (Fig. 5)
should be harvested so that it
can overlap the osteotomy site
of the recipient bone, to enhance the bone-healing. The
segment of diaphysis should not
extend beyond the proximal
two-thirds in order to preserve
an adequate vascular supply to
the periosteum.
The proximal tibiofibular
joint is then opened, with care
taken to preserve as much of the
lateral collateral ligament of the
knee as possible. The biceps
femoris tendon is divided longitudinally (Fig. 6), and the posterior strip is incorporated in the
graft in order to reinforce the
soft-tissue repair at the recipient site. The anterior half is sutured to the lateral collateral
ligament, which is going to be
fixed to the lateral aspect of the
tibial metaphysis. Finally, the
proximal dissection of the pedicle is carried out until the origin of the anterior tibial artery is
exposed and ligated. In order to
obtain a longer and more conveniently located pedicle, this graft
has been hemodynamically
modified according to a reverse
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CRITICAL CONCEPTS | continued
PITFALLS:
Injury to the recurrent epiphyseal branch of the anterior tibial
artery during the dissection is
the major technical mistake. To
prevent this complication, which
substantially reduces the value
of this procedure, a direct dissection of the fragile epiphyseal
vessels should be avoided and
they should be protected with a
full-thickness muscular cuff
consisting of the proximal portion of the extensor digitorum
longus and peroneus longus
muscles.
FIG. 5
A redundant periosteal flap should be saved and included in the harvest.
In addition, the diaphyseal musculoperiosteal branches to the
fibula are very thin (Fig. 10),
and they cannot be dissected
safely. Once again, a certain
amount of soft tissue around
the pedicle, including the interosseous membrane (Figs.
11-A and 11-B) and a longitudinal strip of muscle (Fig. 12) that
contains the tiny perforator arteries to the fibular periosteum,
should be preserved.
Finally, great care should be
taken in dissecting the peroneal
nerve from the vascular pedicle.
The motor branches to the anterior and lateral muscles are
quite thin and fragile and require a very tedious and gentle
dissection. If a motor branch is
severed, it should be repaired
with use of a microsurgical
technique.
flow model. The long distal portion of the pedicle is therefore
preferred for anastomosis to the
recipient vessels. As has been reported in the literature5 and
FIG. 6
The biceps femoris tendon is split longitudinally. The posterior half is harvested with the
bone, and the anterior half is used to reinforce the lateral collateral ligament and then is
fixed to the lateral aspect of the tibial metaphysis.
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FIG. 7-A
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FIG. 7-B
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FIG. 7-C
Figs. 7-A, 7-B, and 7-C Reconstruction of the distal part of the radius. Fig. 7-A Osteosynthesis with a compression plate is preferred when
a sufficiently long proximal radial stump is available after the resection. Fig. 7-B In the case of total resection of the radius, the vascularized fibula is fixed, end to side, to the ulna. Fig. 7-C When the distal aspect of the ulna also is resected, a one-bone forearm is the only
possible option.
confirmed by our clinical experience, the venous flow can be
reversed, provided that the
small shunts that interconnect
the two venae comitantes are
preserved during the dissection
of the vascular bundle. Usually,
only one of the two venae comitantes has adequate flow, and
the surgeon should be aware of
which vein is the better choice
for the anastomosis in the recipient site.
Care is taken when repairing the lateral structures that stabilize the knee joint. The lateral
collateral ligament, enhanced by
the residual portion of the biceps femoris tendon, is fixed to
the lateral aspect of the tibia with
nonabsorbable sutures into the
periosteum, and stability is evaluated. The donor extremity is
protected by an above-the-knee
cast, which should be worn for
one month.
Reconstruction of the
Distal Part of the Radius
Fixation of the proximal part of
the fibula to the distal part of
the radius can be achieved ei-
ther with a plate and screws
(Fig. 7-A) or with lag screws if a
step-cut osteotomy is performed. Either procedure is facilitated by the similarity
between the diameters of the
donor and recipient bones. In
the case of a total resection of
the radius, the fibula should be
fixed, end to side, to the ulna
(Fig. 7-B) with lag screws in order to achieve adequate stability. When the distal part of the
ulna has been resected as well,
the fibula should be fixed to the
residual proximal part of the
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FIG. 9
Preoperative angiography of the donor extremity. The recurrent epiphyseal branch (arrow) arises from the
anterior tibial artery approximately 2
cm from its origin.
FIG. 8
Illustration of the use of the biceps femoris tendon in the reconstruction of the soft tissue of the wrist. The tendon is woven into the distal capsule and ligaments and then is
anchored to a residual portion of the interosseous membrane.
ulna to create a one-bone forearm (Fig. 7-C).
The wrist is temporarily
stabilized with a 1.2-mm Kirschner wire, which is removed one
month postoperatively. The
strip of biceps femoris tendon
remaining attached to the fibular head is used for soft-tissue
repair and is anchored to the remaining distal radiocarpal capsule and ligaments (Fig. 8). In
contrast, the distal radioulnar
joint is usually left slightly lax in
order to prevent any possible
impingement during pronation
and supination.
A reverse-flow arterial end-
to-end anastomosis is then performed with either the radial artery or the common interosseous
artery. The recipient vein is usually the cephalic vein. At the end
FIG. 10
Note the thin musculoperiosteal arteries (arrows) to the fibular diaphysis that arise from
the anterior tibial artery and perforate the extensor digitorum longus and peroneus longus muscles.
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FIG. 11-A
Figs. 11-A and 11-B The interosseous
membrane is sharply detached from the
tibia and included in the graft. The vascular
pedicle and its branches should maintain
the connection with the interosseous
membrane.
FIG. 11-B
FIG. 12
A cuff of muscle (purple area) should be included in the
harvest in order to preserve the musculoperiosteal
branches (red line) to the diaphysis.
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of the vascular repair, bleeding
should be observed from the
muscular cuff surrounding the
transferred proximal part of the
fibula. An above-the-elbow cast
is worn during the first two
months postoperatively and is
then replaced with a wrist
splint.
Marco Innocenti, MD
Luca Delcroix, MD
Massimo Ceruso, MD
Rodolfo Capanna, MD
Division of Hand Surgery and Reconstructive
Microsurgery (M.I., L.D., and M.C.); and Department of Orthopaedics, Musculoskeletal Tumor
Center (R.C.); Azienda Ospedaliera Careggi,
C.T.O., Largo Palagi, 1 50139 Florence, Italy.
E-mail address for M. Innocenti:
[email protected]
S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 ·
Marco Manfrini, MD
Istituto Ortopedico Rizzoli, Via Pupilli 1, I-40136
Bologna, Italy
The authors did not receive grants or outside funding in support of their research or preparation of
this manuscript. They did not receive payments or
other benefits or a commitment or agreement to
provide such benefits from a commercial entity.
No commercial entity paid or directed, or agreed
to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
The line drawings in this article are the work of
Joanne Haderer Müller of Haderer & Müller
([email protected]).
doi.10.2106/JBJS.E.00295
REFERENCES
1. Innocenti M, Ceruso M, Manfrini M, Angeloni R, Lauri G, Capanna R, Bufalini C. Free
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vascularised growth-plate transfer after bone
tumor resection in children. J Reconstr Microsurg. 1998;14:137-43.
2. Innocenti M, Ceruso M, Delcroix L. Vascularised epiphyseal transfer in upper limb skeletal reconstruction in children. Indications
and operative technique. In: Schuind F, de
Fontaine S, Van Geertrayden J, Soucacos PN,
editors. Advances in upper and lower extremity microvascular reconstructions. Singapore:
World Scientific; 2002. p 90-105.
3. Taylor GI, Wilson KR, Rees MD, Corlett RJ,
Cole WG. The anterior tibial vessels and their
role in epiphyseal and diaphyseal transfer of
the fibula: experimental study and clinical applications. Br J Plast Surg. 1988;41:451-69.
4. Bonnel F, Lesire M, Gomis R, Allieu Y, Rabischong P. Arterial vascularization of the fibula microsurgical transplant techniques.
Anatomia Clinica. 1981;3:13-22.
5. del Pinal F, Taylor GI. The deep venous system and reverse flow flaps. Br J Plast Surg.
1993;46:652-64.
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This is an enhanced PDF from The Journal of Bone and Joint Surgery
The PDF of the article you requested follows this cover page.
Reconstruction of the Posterior Cruciate Ligament with a Mid-Third
Patellar Tendon Graft with Use of a Modified Tibial Inlay Method
Young-Bok Jung, Ho-Joong Jung, Suk-Kee Tae, Yong-Seuk Lee and Kee-Hyun Lee
J Bone Joint Surg Am. 87:247-263, 2005. doi:10.2106/JBJS.E.00203
This information is current as of September 3, 2005
Reprints and Permissions
Click here to order reprints or request permission to use material from this
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The Journal of Bone and Joint Surgery
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www.jbjs.org
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COPYRIGHT © 2005
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Reconstruction of the
Posterior Cruciate Ligament
with a Mid-Third Patellar
Tendon Graft with Use of a
Modified Tibial Inlay Method
Surgical Technique
By Young-Bok Jung, MD, Ho-Joong Jung, MD, Suk-Kee Tae, MD, Yong-Seuk Lee, MD, and Kee-Hyun Lee, MD
Investigation performed at the Department of Orthopaedic Surgery, Medical Center of Chung-Ang University, Seoul, South Korea
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 1878-1883, September 2004
INTRODUCTION
Although many arthroscopic techniques for reconstructing the posterior cruciate ligament have been
reported, most are modifications of a transtibial
tunnel technique through an anterior approach1-7.
However, excessive angular deformity of the graft at
the posterior opening of the tibial tunnel may result
in failure and stretching of the graft. The tibial inlay
technique8 avoids the problem of abrasion of the
ligament graft on the tunnel margin and allows the
graft to pass easily through the femoral tunnel. A
disadvantage of the tibial inlay technique has been
exposure of the popliteal fossa with the patient in
the prone or lateral decubitus position. The purpose of this report is to present a modification of
this method in which the patient is positioned supine throughout the procedure.
SURGICAL TECHNIQUE
The patient is placed in the supine position, and
general anesthesia is induced. The end of the operating table is lowered so that the patient’s knee can
ABSTRACT
BACKGROUND:
The tibial inlay method for reconstruction of the posterior cruciate ligament has been performed with the patient in the prone or lateral decubitus position. The
purpose of this report is to present a modification of
this method wherein the patient is positioned supine
throughout the procedure.
METHODS:
Between May 1995 and September 1998, twelve patients who had an isolated tear of the posterior cruciate ligament underwent reconstruction with use of the
modified tibial inlay technique. Eleven patients were
evaluated after a minimum duration of follow-up of two
years. Stability was measured on posterior stress radiographs and with a maximum manual displacement
test performed with a KT-1000 arthrometer. Clinical
evaluation was carried out with use of the scoring
systems of the Orthopädische Arbeitsgruppe
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flex to 90°. The arthroscope is
introduced through a high anterior arthroscopic portal, and the
intra-articular structures are ex-
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amined; meniscal surgery is
performed when needed. A 10mm-wide graft is taken from the
central third of the patellar ten-
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don, with segments of bone
from the inferior pole of the patella and the tibial tubercle incorporated in continuity.
FIG. 1
The center of the femoral tunnel is 5 to 6 mm proximal to the articular cartilage at the eleven o’clock position (left knee).
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ABSTRACT | continued
Knie and the International Knee
Documentation Committee.
Second-look arthroscopy was
performed in five patients at the
time of follow-up.
RESULTS:
The mean side-to-side difference in displacement (and standard deviation) was reduced
from 10.8 ± 1.9 mm preoperatively to 3.4 ± 2.4 mm at the
time of follow-up as measured
on the stress radiographs, and
it was reduced from 9.0 ± 2.1
mm preoperatively to 1.8 ± 1.2
mm at the time of follow-up as
measured with the KT-1000
arthrometer. The average Orthopädische Arbeitsgruppe Knie
score was improved from
71.6 ± 6.8 to 92.5 ± 4.8
points. All eleven patients had
a satisfactory clinical outcome
at the time of the final clinical
evaluation. The second-look arthroscopic examination in the
five patients showed no evidence of partial tearing or abrasion of the graft.
FIG. 2-A
The exposure of the distal femoral cortex for the femoral tunnel.
With use of a high anteromedial portal, the tip of an ante-
rior cruciate ligament tibial
guide (Acufex Microsurgical,
CONCLUSIONS:
Use of our modified tibial inlay
technique for reconstruction of
the posterior cruciate ligament
achieved a good clinical result in
eleven of twelve patients. The
advantages of the technique are
(1) minimal tendon abrasion at
the posterior opening of the tibial tunnel, and (2) elimination of
the need to change the patient’s
position during surgery.
FIG. 2-B
A guide pin is placed for the femoral tunnel.
Mansfield, Massachusetts, 1988)
is placed 5 to 6 mm proximal to
the margin of the articular carti-
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FIG. 3-A
An 18-gauge wire loop.
FIG. 3-B
The wire loop is directed toward the medial side of the
remnant of the posterior cruciate ligament.
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CRITICAL CONCEPTS
INDICATIONS:
The indications for this method are
mainly chronic posterior cruciate
ligament injuries. Previously, we
presented the advantages of our
method compared with the transtibial method and Berg’s original
method8. Our current method is appropriate when the injury is chronic
and the remnant of the posterior
cruciate ligament is thick and of
good quality.
CONTRAINDICATIONS:
There are no absolute contraindications, but this method may not be
advisable following an acute injury.
In that situation, the transtibial
method, which can preserve the
original posterior cruciate ligament
fibers, is believed to be better than
the inlay method because we think
that the original fibers heal along
with the new graft and the new graft
guides the injured posterior cruciate ligament, acting like a stent
and helping the healing process.
FIG. 4
The operating table is tilted down on the affected side for the posterior approach.
continued
FIG. 5
A gently curved longitudinal incision is made in the posteromedial
aspect of the knee.
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FIG. 6
The medial border of the medial head of the gastrocnemius muscle is identified, and the interval between it and the semimembranosus
tendon is developed, exposing the posterior aspect of the joint capsule.
lage of the medial femoral
condyle at approximately the one
o’clock position in the right knee
and at the eleven o’clock position
in the left knee9 (Fig. 1). The distal femoral cortex is exposed medially through a 3 to 5-cm-long
skin incision, the vastus medialis
is elevated subperiosteally, and
the guide pin is placed (Figs. 2-A
and 2-B). A tunnel is then created through the medial femoral
condyle with use of a cannulated
drill. We start the femoral tunnel
with a 6 or 7-mm cannulated
drill bit and then dilate it manually with 8, 9, and 10-mm cannulated drill bits used sequentially.
The tunnel edge is chamfered
with rasps. An 18-gauge wire
loop is passed through the femo-
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Fig. 7-A The popliteus muscle is exposed
between the medial head of the gastrocnemius and the semimembranosus
tendon.
Fig. 7-B The posteromedial surface of the
proximal part of the tibia is exposed by
subperiosteal detachment of the popliteus muscle. The dotted line indicates the
longitudinal incision of the popliteus muscle, which is detached subperiosteally.
FIG. 7-A
FIG. 7-B
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CRITICAL CONCEPTS | continued
PITFALLS:
• The site of the distal femoral
skin incision is located at onethird of the distance from the
medial epicondyle to the medial border of the patella, as
the femoral tunnel is placed in
the eleven o’clock position in
the left knee. Thus, the vastus
medialis should be elevated
from medially, rather than split.
• When the 18-gauge wire loop is
passed through the femoral
tunnel and directed toward the
medial side of the posterior cruciate ligament remnant, the tibia
must be reduced for easy passage and the wire must not be
passed beneath the meniscus.
• The posterior approach is easy
with the patient in the supine
position when the operating table is tilted to its maximal extent. The security belt must be
locked at the patient’s chest
level preoperatively, and the assistant must be positioned on
the tilted side in case the patient starts to slide off the table.
• When the gastrocnemius is retracted laterally, it is helpful to
place a Steinmann pin temporarily into the lateral side of the
proximal part of the tibia to
hold the gastrocnemius and
thereby provide a wide view.
• According to our recent
reports11, posterolateral rotatory instability is commonly
combined with injury of the
posterior cruciate ligament. A
reconstruction of the posterior
cruciate ligament could fail if
the posterolateral injury is not
treated12.
continued
FIG. 8-A
The bone block of the tibial attachment site of the posterior cruciate ligament is detached with use of a curved osteotome, and a trough is created.
ral tunnel and directed toward
the medial side of the remnant of
the posterior cruciate ligament
on the tibia; it is used later to
pass the patellar tendon graft
from the area of the tibial insertion of the posterior cruciate lig-
ament into the femoral tunnel
(Figs. 3-A and 3-B).
For the posterior approach
to the knee, the foot is placed on
a side-table; the hip is flexed, abducted, and externally rotated;
and the knee is flexed 60° to 90°
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FIG. 8-B
Traction is applied to the tibial
attachment of the posterior
cruciate ligament with the suture. (The arrow indicates the
bone block of the tibial attachment of the posterior cruciate
ligament.)
FIG. 9
A 6.5-mm cannulated screw
and a spiked washer are used
to fix the graft to the tibia.
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to provide access to the popliteal
area10. The operating table is
tilted 30° so that the operatively
treated knee is lower than the
contralateral knee (Fig. 4). A 5 to
8-cm-long gently curved longitudinal incision is made in the posteromedial aspect of the knee
(Fig. 5).
Next, the interval between
the medial head of the gastrocnemius muscle and the semimembranosus tendon is
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identified and is developed
bluntly. The semimembranosus
and semitendinosus tendons are
retracted toward the medial
side. The gastrocnemius muscle
is retracted laterally, with protection of the popliteal neurovascular structures (Fig. 6). If
the branches of the inferior medial geniculate artery and vein
are encountered near the midposterior portion of the capsule, they are ligated securely.
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The popliteus muscle is detached subperiosteally from the
posteromedial surface of the
proximal part of the tibia, and
the posterior slope of the proximal part of the tibia is palpated
(Figs. 7-A and 7-B). The posterior aspect of the knee capsule is
then incised adjacent to the medial femoral condyle, and any
remaining fibers of the posterior
cruciate ligament are preserved.
The tibial attachment of the
FIG. 10-A
Radiographs of a twenty-seven-year-old professional soccer player who sustained injuries to the anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament in a soccer game. A stress test with use of the Telos device showed an 11-mm side-to-side difference with an anterior drawer and a 9-mm difference with a posterior drawer.
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posterior cruciate ligament is
demarcated as a 1.5 × 2-cm area
with use of an osteotome, and a
3-mm-thick flap is elevated subperiosteally (Figs. 8-A and 8-B).
Any remnant of the posterior
cruciate ligament is retracted
laterally, and a bone trough,
equal in size to the tibial tuber-
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cle portion of the patellar tendon graft, is made in the
proximal part of the posterior
tibial cortex. The tendon graft
traction sutures are passed with
the wire loop from the tibial attachment area of the posterior
cruciate ligament into the femoral tunnel, and the graft is
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pulled up through the knee joint
into the femoral tunnel. The operating table is taken out of the
30° sideways-tilted position and
is placed in neutral, the position of the bone plug in relation
to the edge of the femoral tunnel is confirmed with arthroscopy, and an interference screw
FIG. 10-B
Postoperative stress radiographs made four years after reconstruction of the posterior cruciate ligament with the modified tibial inlay
method and reconstruction of the anterior cruciate ligament show a 1-mm side-to-side difference with an anterior drawer and a 2-mm difference with a posterior drawer. The patient continued to play professional soccer at the time of writing.
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Figs. 11-A and 11-B The autogenous four-bundle hamstring tendon
graft (black arrow) is pulled up
through the knee joint under the
bone block (white arrow) of the tibial
attachment of the posterior cruciate
ligament.
FIG. 11-A
FIG. 11-B
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FIG. 12-A
The graft is fixed on the medial side, and the
bone block is fixed just lateral to the graft
without damaging it.
FIG. 12-B
Both a screw and a staple can be used
to achieve secure fixation.
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FIG. 13-A
Radiographs of a twenty-eight-year-old athlete who sustained a combined injury of the anterior and posterior cruciate ligaments while practicing Judo. A stress test with use of the Telos device showed a 4-mm side-to-side difference with an anterior drawer and a 16-mm difference with a posterior drawer.
is used to fix the graft in the
femoral tunnel. The operating
table is then retilted to the 30°
position.
An anteriorly directed force
is applied to the proximal part of
the tibia with the knee in 70° of
flexion. A 6.5-mm cannulated
screw and a spiked washer or
staples are then used to secure
fixation of the graft to the tibia
(Fig. 9). The operating table is
changed back to the neutral position, and the final arthroscopic examination is done with
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FIG. 13-B
Postoperative stress radiographs made three years after reconstruction of the posterior cruciate ligament with use of the updated modified
tibial inlay method (tensioning of the remnant of the posterior cruciate ligament and reconstruction of the anterolateral bundle) and reconstruction of the anterior cruciate ligament show no side-to-side difference with an anterior drawer and a 2-mm difference with a posterior
drawer. The patient continued to participate in Judo at the time of writing.
the knee in 90° of flexion to
check the tension of the posterior cruciate ligament graft.
For the first two or three
weeks after surgery, a long leg
splint is used to hold the knee in
extension. It has a posterior pad
that prevents the tibia from sagging posteriorly. Straight-legraising and quadriceps-setting
exercises are begun the day after
the surgery, and the patient is al-
lowed partial weight-bearing
with use of crutches. Starting on
the second postoperative day,
the splint is removed once or
twice a day and the patient is encouraged to perform passive
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range-of-motion exercises to 30°
of flexion; he or she uses both
hands to support the proximal
part of the tibia or performs
these exercises in the prone position to prevent tibial sagging.
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The range of flexion is increased to 90° by the fourth
postoperative week and to 140°
by the sixth to twelfth postoperative week. Full weight-bearing
is begun by the sixth week. At
CRITICAL CONCEPTS | continued
AUTHOR UPDATE:
In the original study, all patients
were treated with a bone-patellar
tendon-bone graft. Currently, we
also use a four-bundle hamstring
graft or Achilles allograft. We reconstruct the posterior cruciate ligament with use of the doublebundle method when the remnant
of the posterior cruciate ligament
is thin and of poor quality. The
Achilles bone block is placed in
the posterior tibial trough and fixed
with a cannulated screw. When
more than six months have
elapsed since the injury and ligament continuity is demonstrated
on magnetic resonance imaging,
we tension the remnant of the posterior cruciate ligament and reconstruct the anterolateral bundle
with a four-bundle hamstring graft.
The femoral portion of the procedure is done with the method described above. On the tibial side,
the method is somewhat different,
as follows. The posterior aspect of
the knee joint capsule is incised
adjacent to the medial femoral
condyle, and fibers of the posterior
cruciate ligament remnant are preserved. The tibial attachment of
the posterior cruciate ligament is
demarcated as a 1.5 × 2-cm area
with use of an osteotome, and a 7mm-thick bone block is detached
from distal to proximal with use of
a 1.2 to 1.5-cm-wide curved osteotome. At the junction of the
bone and the remnant of the posterior cruciate ligament, a
number-5 nonabsorbable suture is
placed to provide distal traction on
the remnant. A bone trough is
made just medial to the tibial insertion of the posterior cruciate
ligament and just distal to the
bone-block detachment site. The
tendon graft traction sutures are
passed with a wire loop from the
tibial insertion area of the posterior cruciate ligament into the femoral tunnel, and the graft is pulled
up through the knee joint into the
femoral tunnel and secured (Figs.
11-A and 11-B). The autogenous
four-bundle hamstring graft is
then fixed to the cortical bone of
the distal and medial sides of the
tibial insertion of the posterior cruciate ligament with a 10-mm staple. Then, the remnant of the
posterior cruciate ligament is tensioned by pulling the bone block
distally. The knee joint is flexed
70° to 90° to ensure a reduction
between the medial femoral
condyle and the medial tibial
plateau. The posterior cruciate ligament bone block is first temporarily fixed to the hamstring graft
with use of one or two Kirschner
wires, and then a 5.0 or 6.5-mm
cannulated screw with a spiked
washer is used to securely fix the
bone block to the tibia. During insertion of the cannulated screw,
care is taken to avoid damaging
the hamstring tendon graft. When
the fixation is not firm, additional
fixation is performed with a staple
(Figs. 12-A through 13-B).
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three to six weeks after the surgery, a posterior cruciate ligament brace with a tibial
supporter is applied. By the
third to sixth postoperative
month, a progressive program
of running is initiated if the
knee is asymptomatic with this
activity. By the eighth to tenth
postoperative month, sports activities such as soccer can be resumed if rehabilitation has
proceeded satisfactorily (Figs.
10-A and 10-B).
Young-Bok Jung, MD
Ho-Joong Jung, MD
Suk-Kee Tae, MD
Yong-Seuk Lee, MD
Kee-Hyun Lee, MD
Department of Orthopaedic Surgery, Medical Center of Chung-Ang University, 224-1, Heukseokdong, Dongjak-ku, 156-070, Seoul, South Korea.
E-mail address for Y.-B. Jung:
[email protected]
The authors did not receive grants or outside funding in support of their research or preparation of
this manuscript. They did not receive payments or
other benefits or a commitment or agreement to
provide such benefits from a commercial entity.
No commercial entity paid or directed, or agreed
to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
The line drawings in this article are the work of
Jennifer Fairman ([email protected]).
doi:10.2106/JBJS.E.00203
REFERENCES
1. Clancy WG Jr. Repair and reconstruction
of the posterior cruciate ligament. In: Chapman MW, editor. Operative orthopaedics.
Volume 3. Philadelphia: JB Lippincott; 1998.
p 1651-65.
2. Feagin JA Jr, editor. The crucial ligaments:
diagnosis and treatment of ligamentous injuries about the knee. New York: Churchill Livingstone; 1988. p 71-106.
3. Fenton PJ, Paulos LE. Posterior cruciate ligament reconstruction with allograft augmentation. Sports Med Arthrosc Rev.
1994;2:129-36.
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4. Insall JN, editor. Surgery of the knee.
New York: Churchill Livingstone; 1984.
p 384-7.
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Arthroscopy. 1997;13:661-5.
7. Schulte KR, Chu ET, Fu FH. Arthroscopic
posterior cruciate ligament reconstruction.
Clin Sports Med. 1997;16:145-56.
5. Mariani PP, Adriani E, Santori N, Maresca
G. Arthroscopic posterior cruciate ligament
reconstruction with bone-tendon-bone patellar graft. Knee Surg Sports Traumatol Arthrosc. 1997;5:239-44.
8. Berg EE. Posterior cruciate ligament tibial
inlay reconstruction. Arthroscopy.
1995;11:69-76.
6. Pinczewski LA, Thuresson P, Otto D,
Nyquist F. Arthroscopic posterior cruciate ligament reconstruction using four-strand hamstring tendon graft and interference screws.
9. Ogata K, McCarthy JA. Measurements of
length and tension patterns during reconstruction of the posterior cruciate ligament.
Am J Sports Med. 1992;20:351-5.
JBJS . ORG
10. Jung YB, Tae SK, Yum JK, Koo BH. The results of posterior cruciate ligament reconstruction: transtibial two tunnel technique vs.
modified tibial inlay technique. J Korean Arthrosc Soc. 1998;2:135-40.
11. Jung YB. Unpublished data.
12. Harner CD, Vogrin TM, Höher J, Ma CB,
Woo SL. Biomechanical analysis of a posterior cruciate ligament reconstruction. Deficiency of the posterolateral structures as a
cause of graft failure. Am J Sports Med.
2000;28:32-9.
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The PDF of the article you requested follows this cover page.
Stiffness After Total Knee Arthroplasty
Charles L. Nelson, Jane Kim and Paul A. Lotke
J Bone Joint Surg Am. 87:264-270, 2005. doi:10.2106/JBJS.E-00345
This information is current as of September 3, 2005
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COPYRIGHT © 2005
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Stiffness After
Total Knee Arthroplasty
Surgical Technique
By Charles L. Nelson, MD, Jane Kim, BA, and Paul A. Lotke, MD
Investigation performed at the Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 1479-1484, July 2004
ABSTRACT
BACKGROUND:
Stiffness is an uncommon but
disabling problem after total
knee arthroplasty. The prevalence of stiffness after knee replacement has not been well
defined in the literature. In addition, the outcomes of revision
surgery for a stiff knee following
arthroplasty have not been evaluated in a large series of patients, to our knowledge. The
purposes of this study were to
define the prevalence of stiffness after primary total knee arthroplasty and to evaluate the
efficacy of revision surgery for
treatment of the stiffness.
METHODS:
We defined a stiff knee as one
having a flexion contracture of
15° and/or <75° of flexion. Two
separate groups were evaluated.
First, the results of 1000 consecutive primary total knee replacements were reviewed to
determine the prevalence of
stiffness. Second, the results of
fifty-six revisions performed
continued
INTRODUCTION
Stiffness is a disabling problem following total knee arthroplasty.
Most patients have both pain and diminished functional capacity
in association with the knee stiffness. Management requires careful
evaluation to determine the etiology of the stiffness as well as
precise surgical technique to correct the problem while avoiding
complications.
A comprehensive clinical evaluation is performed to exclude
or identify extrinsic sources of knee stiffness. These may include
severe osteoarthritis of the ipsilateral hip, neurologic injury leading
to muscle rigidity, tight quadriceps or hamstring muscles secondary to muscle injury, heterotopic ossification, or long-standing
juvenile inflammatory conditions limiting knee range of motion
prior to the completion of skeletal growth. When extrinsic sources
are identified, revision total knee arthroplasty is unlikely to be
associated with a favorable outcome without correction of the
extrinsic problem.
Following the exclusion of extrinsic sources of knee stiffness, the
goal is to identify a specific intrinsic etiology that can be corrected. Potential intrinsic causes of knee stiffness include (1) overstuffing of the
patellofemoral articulation, (2) an excessively tight flexion and/or extension gap, (3) a tight posterior cruciate ligament, (4) femoral and/or
tibial malrotation, (5) arthrofibrosis, and (6) limited bearing excursion in association with a highly conforming mobile-bearing prosthetic design.
Overstuffing of the patellofemoral articulation may result from
anterior displacement of the anterior flange of the femoral component due to oversizing of the femoral component or from anterior
translation of an appropriately sized femoral component. It also occurs after patellar resurfacing if the patellar component composite
thickness is increased.
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Decreased flexion may be
associated with a tight flexion
gap. This occurs when the
amount of posterior femoral
condylar bone that is resected is
less than the thickness of the
posterior condyles of the femoral component. Decreased extension may result from a tight
extension gap when the distal
femoral resection is too distal or
the tibial insert is too thick. Radiographs of the ipsilateral knee
that are made before knee replacement or radiographs of the
contralateral knee allow for the
assessment of optimal sizing
and bone resection.
When a posterior cruciate
ligament-preserving knee design
is utilized, limited knee flexion
may result if the posterior cruciate ligament is too tight. Williams et al. reported improved
flexion and good results following arthroscopic release of the
posterior cruciate ligament in
these patients1.
Femoral or tibial malalignment or malrotation may lead
to pathologic tightness of softtissue structures about the knee.
Malalignment tends to lead to
asymmetry of the extension gap.
Malrotation may result either in
asymmetry of the flexion gap or
patellar tracking problems, both
of which may lead to diminished
flexion.
Arthrofibrosis involves excessive pathologic postoperative
scarring, which directly inhibits
flexion and/or extension. It is
one of the most unresponsive
causes of stiffness.
Finally, bone impingement
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ABSTRACT | continued
because of stiffness, sometimes
associated with pain or component
loosening, after primary total knee
arthroplasty were evaluated.
from 40.0 to 58.4 points; and the
mean Knee Society pain score,
from 15.0 to 46.9 points. The
mean flexion contracture decreased from 11.3° to 3.2°, the
mean flexion improved from 65.8°
to 85.4°, and the mean arc of motion improved from 54.6° to 82.2°.
The arc of motion improved in 93%
of the knees, and flexion increased in 80%. Extension improved in 63%, and it remained
unchanged in 30%.
RESULTS:
The prevalence of stiffness was
1.3%, at an average of thirty-two
months postoperatively. The patients with a stiff knee had had
significantly less preoperative extension and flexion than did those
without a stiff knee (p < 0.0001).
There were no significant differences in age, gender, implant design, diagnosis, or the need for
lateral release between the patients with and without stiffness.
The second cohort, of knees revised because of stiffness, were
followed for an average of fortythree months. The mean Knee Society score improved from 38.5
points preoperatively to 86.7
points at the time of follow-up; the
mean Knee Society function score,
resulting from osteophytes or
postoperative heterotopic bone
also can limit motion.
SURGICAL TECHNIQUE
Intravenous prophylactic antibiotics are administered preoperatively. Optimally, we prefer the
use of an epidural and/or femoral nerve catheter to facilitate
immediate range of motion postoperatively. The tourniquet may
or may not be inflated, according
to the preference of the surgeon.
The prior anterior skin incision is excised and extended as
necessary. Safe and adequate exposure is the key element to the
CONCLUSIONS:
The prevalence of stiffness in our
series of 1000 primary knee arthroplasties was 1.3%. Revision
surgery was a satisfactory treatment option for stiffness, as the
Knee Society scores improved, the
flexion contractures diminished,
and 93% of the knees had an increased arc of motion. However,
the results suggest that the benefits are modest.
surgical approach. Patellar tendon avulsion is a disastrous
complication of revision total
knee arthroplasty and can be
avoided with good exposure. We
prefer to utilize a medial parapatellar arthrotomy for these patients as this approach affords
the best exposure, is extensile,
and allows for modifications to
minimize the risk of patellar
tendon avulsion. Following the
arthrotomy, the first step is to
reestablish medial and lateral
gutters, making certain that the
extensor mechanism moves independently from the synovium, scar tissue, and femur.
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Most patients require a formal
synovectomy, with excision of
the synovium along with the
dense scar tissue that encapsulates the entire joint.
A medial sleeve is developed
around the medial aspect of the
tibia in the plane of the semimembranosus bursa. This sleeve
may be extended subperiosteally
around the posterior aspect of
the tibia. The creation of this
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sleeve allows for marked external
rotation of the tibia, which
moves the tibial tubercle laterally and allows subluxation of the
patella with less tension on the
patellar tendon. Occasionally,
dense adhesions will need to be
released in order to allow sufficient tibial external rotation.
During surgery, we prefer
patellar subluxation to eversion.
Patellar tendon avulsion is more
FIG. 1
Illustration depicting a medial parapatellar arthrotomy (solid line) and quadriceps snip
modification (blue dashed line). It is important to keep the longitudinal incision in the
tendon and to extend it proximally to the top of the tendon before creating an oblique incision (quadriceps snip) at the proximal extent of the tendon. A transverse or oblique incision across the quadriceps tendon closer to the patella (black dashed line) must be
avoided as this may be associated with postoperative extensor mechanism disruption.
JBJS . ORG
likely when its fibers are twisted
following eversion. If the patella
cannot be mobilized laterally because of excessive tension on the
patellar tendon, a lateral retinacular release is performed. The
retinaculum is incised between 1
and 2 cm from the lateral border
of the patella.
In cases in which there is excessive tension on the patellar
tendon, particularly when a tight
quadriceps muscle interferes
with lateral mobilization of the
patella, a quadriceps snip may be
performed as described by
Insall2,3 (Fig. 1). This approach
releases the proximal tether on
the patella. It is performed by
transecting the quadriceps tendon obliquely, well proximal to
the patella. The quadriceps snip
surgical approach has the advantage of allowing normal postoperative rehabilitation and rangeof-motion exercises. When incising the quadriceps tendon proximally, it is important to stay
within the fibers of the tendon so
that a secure side-to-side closure
can be accomplished.
A tibial tubercle osteotomy
may be required in cases of extreme stiffness combined with
patella infera (Fig. 2). The short
contracted patellar tendon interferes with lateral mobilization of
the patella. Tibial tubercle osteotomies were described in detail by Whiteside4. We prefer a
minimum 6-cm-long tubercle
osteotomy to allow a large surface area for healing. The optimal thickness is approximately 1
cm. The osteotomy is performed
with use of an oscillating saw or
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CRITICAL CONCEPTS
INDICATIONS:
Before revision total knee arthroplasty is considered, the patient should have sufficient pain
and/or functional limitations to
warrant the risks of the procedure. If the patient and surgeon
agree that the pain and functional limitations are sufficient,
the surgeon’s comprehensive
evaluation must rule out extrinsic sources of knee stiffness
before revision total knee arthroplasty is planned. Preoperative
identification of a correctable intrinsic etiology of knee stiffness
leads to a more favorable
risk:benefit ratio than is the
case when no intrinsic problem
is identified preoperatively.
CONTRAINDICATIONS:
Revision total knee arthroplasty is contraindicated whenever there is an unresolvable
extrinsic cause of knee stiffness. The extrinsic problem
should be addressed before or
during the revision knee procedure. Extrinsic causes include
decreased range of motion of
the hip secondary to arthrodesis or severe arthritic involvement, neurologic disorders
leading to extrinsic muscle contractures, and long-standing extrinsic muscle tightness without
neurologic abnormalities, particularly in the setting of juvenile
FIG. 2
Intraoperative photograph showing the site of a tibial tubercle osteotomy. The tibialis anterior remains attached to the osteotomy fragment. The tibial tubercle and the patella
are outlined in methylene blue. Note the short, contracted patellar tendon.
osteotome from medial to lateral,
with care being taken to maintain the lateral soft-tissue attachment and vascularity from the
tibialis anterior. The superior
and inferior aspects of the osteotomy are completed with a
curved osteotome. The proximal
extent of the osteotomy should
be transverse (Fig. 3) to provide a
mechanical block to proximal
migration. The distal aspect of
the osteotomy should be oblique
to minimize the stress-riser effect, which may predispose to a
tibial shaft fracture (Fig. 3)5. The
osteotomy site is repaired with
use of either screws or stainless
steel wire. Screws allow more
rigid fixation; however, the drillholes weaken the osteotomy fragment and may be associated with
fracture of the tibial tubercle
fragment. In addition, bicortical
fixation may not be possible in
patients with a long, canal-filling
tibial component stem. When
cerclage wires are utilized, they
should be placed at an angle
from distal-medial to proximal-
continued
lateral to minimize proximal migration of the osteotomy fragment. A minimum of two
cerclage wires should be utilized.
In cases of severe stiffness in
which a quadriceps snip is insuffi-
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the femoral and tibial components. Extra care is taken to preserve bone stock.
In cases of preoperative
flexion contracture, posterior
capsular release is critical to allow full extension without joint
line elevation. If residual osteophytes remain on the posterior
aspects of the femoral condyles,
they need to be removed as well.
Scrutiny of preoperative radio-
CRITICAL CONCEPTS | continued
inflammatory arthritic conditions. These disorders will benefit minimally from revision total
knee arthroplasty unless the
underlying extrinsic pathologic
condition is addressed first.
Surgery is also contraindicated
for ill or severely infirm patients
in whom the surgical risks are
too great. The overriding principle determining whether revision total knee arthroplasty is
indicated is whether the patient
and surgeon reasonably believe
that the surgical risk is less
than the anticipated benefit.
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graphs, and, if available, prearthroplasty radiographs or radiographs of the contralateral
knee, is important in order to
make certain that the femoral
component is not undersized.
Distal and posterior augments
will allow placement of an appropriately sized femoral component at the normal joint line.
In cases of loss of flexion, it
is important to determine
continued
cient to allow satisfactory patellar
mobilization and a tibial tubercle
osteotomy either is insufficient or
is not desirable, a medial parapatellar arthrotomy may be
modified into a quadriceps V-Y
turndown as described by Insall3,6.
This approach allows the extensor mechanism to be reflected laterally and inferiorly if necessary.
This procedure can disrupt the
entire proximal patellar circulation and may be associated with
a greater risk of osteonecrosis of
the patella. It also requires a modified postoperative rehabilitation
regimen to protect the repaired
quadriceps mechanism from rupture or stretch.
Following satisfactory exposure, the existing implants are removed with use of standard
removal instruments. If a modular tibial component is present,
removal of the polyethylene insert will increase space and allow
better exposure for removal of
FIG. 3
Illustration depicting a tibial tubercle osteotomy site from the lateral view, emphasizing
the transverse nature of the proximal extent of the osteotomy and the oblique nature of
the distal extent of the osteotomy.
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CRITICAL CONCEPTS | continued
PITFALLS:
release soft tissues adequately
The major pitfalls associated with
revision total knee arthroplasty in
the setting of knee stiffness may
be divided into problems that are
associated with the preoperative
evaluation and problems that are
encountered during surgery.
and to position and size components appropriately to allow good
stability and range of motion on
the operating table. An aggressive
analgesic and rehabilitation protocol is then instituted on the presumption that early range of
motion retards scar formation. In
patients with previous heterotopic
ossification, the use of low-dose
radiation therapy7 or a four to sixweek course of indomethacin8 may
prevent recurrence and minimize
stiffness.
The prevention of problems is best
accomplished by appropriate sizing
and prosthetic positioning during
the index arthroplasty procedure.
In patients who lose motion immediately postoperatively, as noted
above, manipulation with the patient under anesthesia, optimally
within the first six weeks, may help
to restore functional knee motion.
The major pitfalls related directly
to the surgical procedure include
the challenge of optimizing the fixation, soft-tissue balance, and
component positioning while
avoiding complications. Because
of the difficulty in exposing the
stiff knee, care must be taken to
avoid patellar tendon avulsion. Patients with long-standing marked
flexion contracture, particularly
when associated with valgus deformity of the knee, also are at increased risk for peroneal nerve or
popliteal vessel injury.
Successful revision of a stiff knee
is predicated on ruling out extrinsic sources of stiffness that are
uncorrectable with revision total
knee arthroplasty. Identifying the
etiology of knee stiffness preoperatively or intraoperatively and assessing whether the problem was
corrected following placement of
the new prosthesis is associated
with the best results. In the uncommon case of idiopathic arthrofibrosis, care is taken to
whether flexion is limited by the
quadriceps mechanism (extrinsic contracture) or whether flexion is limited by impingement or
abnormal tension involving the
deep soft-tissue structures
around the knee.
Following placement of appropriately sized femoral and
tibial trial components in the desired rotation and at the desired
joint line, range of motion and
stability need to be assessed with
the extensor mechanism re-
duced. If flexion is limited, an extrinsically tight quadriceps
muscle is likely to be the cause.
Occasionally, the quadriceps is
adherent to the femur and requires further release to improve
flexion. We try to avoid quadricepsplasty or z-lengthening procedures. Most patients accept
diminished flexion in order to
avoid more disabling quadriceps
weakness and an extensor lag,
which may develop following
pathologic lengthening of the
JBJS . ORG
quadriceps. When the knee is
well balanced and flexion is limited only by a tight quadriceps
mechanism, it has been our
experience that the patient gradually stretches the extensor
mechanism and regains more
flexion. Finally, if the composite
patella-patellar button thickness
is excessive, patellar revision with
resurfacing is necessary.
Once satisfactory range of
motion and stability are demonstrated, the actual femoral and
tibial components are fixed in
identical position. The knee is
closed in a standard fashion, and
a sterile dressing applied.
Postoperatively, we institute
immediate range of motion in a
continuous passive motion machine for most patients. The specific continuous passive motion
protocol is patient-dependent. A
high-flexion continuous passive
motion protocol with a range of
70° to 100° is started in the recovery room, and a protocol with a
range of 0° to 100° is started on
the next postoperative day. We
have found that this routine may
be associated with less blood loss
and earlier return of good knee
flexion; however, care must be
taken to ensure that the patient
maintains full knee extension. In
cases in which the patient had a
notable preoperative flexion contracture, a knee immobilizer or
cylinder cast may be required
and continuous passive motion
may not be used. It is important
to stress that good knee extension is more important than
good knee flexion for gait and
function.
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Optimizing pain control
postoperatively allows the patient to participate more fully
with range-of-motion exercises.
This early motion is even more
important in the setting of arthrofibrosis, in which motion is
important for retarding recurrent scar formation. Knee manipulation may be necessary
when a patient presents with unacceptable range of motion between two and six weeks
postoperatively. However, what
constitutes an acceptable range
of motion is variable and depends on the patient’s body habitus, bone stock, and functional
limitations as well as on the
range of motion that is achieved
intraoperatively. In cases in
which flexion is limited by an extrinsic contracture, cases in
which there is marked osteopenia, and cases in which manipu-
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lation is attempted more than
three months postoperatively,
the risk of iatrogenic fracture increases with excessively forceful
manipulation.
Charles L. Nelson, MD
Jane Kim, BA
Paul A. Lotke, MD
Department of Orthopaedic Surgery, Hospital of
the University of Pennsylvania, 2 Silverstein,
3400 Spruce Street, Philadelphia, PA 19104.
E-mail address for C.L. Nelson:
[email protected]. E-mail address
for J. Kim: [email protected]. E-mail
address for P.A. Lotke: [email protected]
JBJS . ORG
REFERENCES
1. Williams RJ 3rd, Westrich GH, Siegel J,
Windsor RE. Arthroscopic release of the posterior cruciate ligament for stiff total knee arthroplasty. Clin Orthop Relat Res. 1996;331:
185-91.
2. Garvin KL, Scuderi G, Insall JN. Evolution
of the quadriceps snip. Clin Orthop Relat
Res. 1995;321:131-7.
3. Berger RA, Rosenberg AG. Surgical approaches in revision total knee arthroplasty.
In: Lotke PA, Garino JP, editors. Revision total
knee arthroplasty. Philadelphia: LipincottRaven; 1999. p. 157-72.
4. Whiteside LA. Exposure in difficult total
knee arthroplasty using tibial tubercle osteotomy. Clin Orthop Relat Res. 1995;321:32-5.
The authors did not receive grants or outside funding in support of their research or preparation of
this manuscript. They did not receive payments or
other benefits or a commitment or agreement to
provide such benefits from a commercial entity.
No commercial entity paid or directed, or agreed
to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
5. Ritter MA, Carr K, Keating EM, Faris PM,
Meding JB. Tibial shaft fracture following tibial tubercle osteotomy. J Arthroplasty.
1996;11:117-9.
The line drawings in this article are the work of
Jennifer Fairman ([email protected]).
8. Bellemans J, Claerhout P, Eid T, Fabry G.
Severe heterotopic ossifications after total
knee arthroplasty. Acta Orthop Belg.
1999;65:98-101.
doi:10.2106/JBJS.E-00345
6. Insall JN, editor. Surgery of the knee. New
York: Churchill Livingstone; 1984. Surgical
approaches to the knee.p 41-54.
7. Chidel MA, Suh JH, Matejczyk MB. Radiation prophylaxis for heterotopic ossification of
the knee. J Arthroplasty. 2001;16:1-6.
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The PDF of the article you requested follows this cover page.
Total Knee Arthroplasty for Severe Valgus Deformity
Amar S. Ranawat, Chitranjan S. Ranawat, Mark Elkus, Vijay J. Rasquinha, Roberto Rossi and Sushrut Babhulkar
J Bone Joint Surg Am. 87:271-284, 2005. doi:10.2106/JBJS.E.00308
This information is current as of September 3, 2005
Reprints and Permissions
Click here to order reprints or request permission to use material from this
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COPYRIGHT © 2005
BY
THE JOURNAL
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BONE
AND JOINT
SURGERY, INCORPORATED
Total Knee Arthroplasty for
Severe Valgus Deformity
Surgical Technique
By Amar S. Ranawat, MD, Chitranjan S. Ranawat, MD, Mark Elkus, MD, Vijay J. Rasquinha, MD,
Roberto Rossi, MD, and Sushrut Babhulkar, MD
Investigation performed at the Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 2671-2676, December 2004
INTRODUCTION
Approximately 10% of patients requiring total knee arthroplasty have
a valgus deformity (defined as an anatomic valgus of >10°). Correction of the valgus deformity has posed technical challenges and has
produced variable clinical results in terms of correction of the deformity, instability, and the overall results. The valgus deformity may be
caused by rheumatoid arthritis, posttraumatic arthritis, osteoarthritis,
or metabolic bone disease.
The valgus deformity consists of two components: an element of
bone loss with metaphyseal remodeling, primarily from the lateral
femoral condyle and lateral tibial plateau, and a soft-tissue contracture
consisting of tight lateral structures, such as the iliotibial band, lateral
collateral ligament, popliteus tendon, posterolateral capsule, and hamstring muscles1.
Multiple surgical techniques have been described to balance the
soft tissues after correction of a severe valgus deformity during total
knee replacement. The following guide describes the “inside-out
technique.”
SURGICAL TECHNIQUE
Preoperative Radiographic
Evaluation
Weight-bearing anteroposterior, lateral, and sunrise radiographs of
the knee should be assessed for overall coronal alignment in conjunction with an anteroposterior radiograph of the pelvis. The valgus knee
has been classified into three types. A type-I deformity has minimal
valgus and medial soft-tissue stretching. A typical type-II fixed valgus
deformity has a more substantial deformity (>10°) with medial softtissue stretching, as shown in Figures 1 and 2, and shall be the focus of
this technique guide. A type-III deformity is a severe osseous deforDownloaded from www.ejbjs.org on September 3, 2005
ABSTRACT
BACKGROUND:
In 1985, the senior author
(C.S.R.) developed a new softtissue release technique to
balance valgus knees to avoid
unacceptably high rates of lateonset instability and the need
for primary constrained implants. This report describes the
soft-tissue release technique
and its long-term results when
performed in primary total knee
arthroplasty in patients with a
severe valgus knee deformity.
METHODS:
Four hundred and ninety consecutive total knee arthroplasties
were performed by one surgeon
between January 1988 and
December 1992. In this group,
seventy-one patients (eighty-five
knees) had a valgus deformity of
10°. Thirty-two patients (thirtysix knees) died, and four patients (seven knees) were lost to
follow-up, leaving thirty-five patients (forty-two knees) followed
for a minimum of five years.
continued
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ABSTRACT | continued
These twenty-seven women and
eight men had a mean age of
sixty-seven years at the time of
the index operation. The technique included an inside-out
soft-tissue release of the posterolateral aspect of the capsule with pie-crusting of the
iliotibial band and resection of
the proximal part of the tibia
and distal part of the femur to
provide a balanced, rectangular
space. Cemented, posterior
stabilized implants were used
in all knees. Clinical and radiographic evaluations were performed at one, five, and ten
years postoperatively.
RESULTS:
The mean modified Knee Society
clinical score improved from 30
points preoperatively to 93
points postoperatively, and the
mean functional score improved
from 34 to 81 points. The mean
range of motion was 110° both
preoperatively and postoperatively. The mean coronal alignment was corrected from 15°
of valgus preoperatively to 5°
of valgus postoperatively. Three
patients underwent revision
surgery because of delayed infection, premature polyethylene
wear, and patellar loosening in
one patient each. There were no
cases of delayed instability.
CONCLUSIONS:
The inside-out release technique
to correct a fixed valgus deformity in patients undergoing primary total knee arthroplasty is
reproducible and provides excellent long-term results.
FIG. 1
Radiograph of a type-II valgus deformity.
mity after a prior osteotomy
with an incompetent medial
soft-tissue sleeve, which is best
managed with a constrained or
hinged total-knee design.
Attention should always be
focused on both the osseous and
soft-tissue deformities. One
should be aware of distal femoral hypoplasia, posterior femoral
condylar erosion, unusual proximal femoral neck-shaft angles,
and metaphyseal remodeling of
both the femur and the tibia,
which can lead to malalignment
or malrotation of the femoral
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FIG. 2
Preoperative clinical photograph of
the knee shown in Figure 1.
component. Full-length standing radiographs of the lower extremity can help to avoid these
problems.
Fixed flexion contractures
and the amount of medial jointspace opening may influence the
amount of osseous resection necessary to correct the deformity.
Generally speaking, in type-II
fixed valgus deformities in which
the medial joint space on standing anteroposterior radiographs
is >1 cm, less bone than is typically removed should be resected
from both the distal part of the
femur and proximal part of the
tibia in order to allow for softtissue balancing without elevating the joint line or creating an
extension gap that is too large.
The amount of osseous resection
can be templated on the radiographs prior to surgery.
Templating
Anteroposterior Radiograph (Fig. 3)
FIG. 3
Templating
of the preoperative
radiograph.
1. A vertical line is drawn down
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FIG. 5
The alignment rod is centered over the medial third of the tibial tubercle proximally and the mid-talus distally.
FIG. 4
Photograph of the PFC Sigma posterior stabilized
fixed-bearing total knee prosthesis.
the center of the femoral and tibial shafts.
2. On the tibial shaft, a line
is drawn perpendicular to the
first line at the level of the more
involved lateral tibial plateau.
This will be used to give an idea
of the tibial resection that will be
performed. The relative amount
of the osseous resection as well as
the ratio of lateral-to-medial resection can be determined.
3. On the femoral side, a
line is drawn at the level of the
lateral aspect of the distal portion of the femur that is in 3° of
valgus in relation to the vertical
line that was drawn in Step 1.
This line gives an idea of the
amount of osseous resection
needed from the medial and lateral femoral condyles. Coronal
correction with the “inside-out
technique” is based on a 90°
proximal tibial cut and a distal
femoral cut performed in 3° of
valgus to the anatomical axis.
This is done, as opposed to the
typical 5° to 7° of valgus used for
a varus knee, in order to protect
against undercorrection of the
underlying deformity.
Lateral Radiograph
1. On the lateral radiograph, any
posterior osteophytes should be
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identified and outlined with a
marker. During the procedure,
these osteophytes should be removed as they may hinder the
range of motion as well as the
soft-tissue balance.
2. The lateral radiograph is
used for sizing the femoral component, as magnification of the
femoral condyle is greater (by
5% to 7%) on the anteroposterior radiograph.
Preoperative Selection
of Implant
The goals of total knee replacement are to restore the alignment
of the knee, the joint line, the stability of the joint, and the range
of motion; to assure proper patellofemoral tracking; and to apply proper fixation techniques.
While these goals can be accomplished with any total knee re-
FIG. 6
The femoral alignment rod is set at 3° of valgus during the rough anterior cut and the distal femoral cut.
placement design, we believe that
there are inherent advantages to
the use of a posterior stabilized
design when correcting the valgus deformity (Fig. 4). First, the
posterior stabilized design is inherently more stable than a cruciate-retaining design as a result
of the post-cam mechanism and
joint surface conformity. Thus, it
is applicable to most deformities. Second, the posterior stabilized design allows for greater
lateralization of the femoral and
tibial components, which greatly
improves patellar tracking and
minimizes the need for lateral
retinacular releases. Finally, this
technique involves complete
resection of the posterior cruciate ligament, obviating any
advantage offered by a cruciateretaining design.
FIG. 7
A spacer block is used to check knee ligamentous stability.
Patient Positioning
After spinal anesthesia has been
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with use of an osteotome or
electrocautery to create a small
medial sleeve of tissue. The patella is then everted after releasing the patellofemoral ligament,
and the knee is fully flexed to
expose the cruciate ligaments
and the menisci. Use of a poste-
CRITICAL CONCEPTS
INDICATIONS:
Type-I and II valgus deformities
of the knee with severe arthritis
CONTRAINDICATIONS:
Type-III valgus deformities
continued
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rior stabilized implant requires
release of both cruciate ligaments at this point. The menisci are excised, and the tibia is
maximally flexed and externally
rotated to expose the entire tibial plateau. The knee is stabilized in flexion by placing the
administered, the patient is
positioned supine on the operating table. A tourniquet is
placed high on the thigh, and
the knee is shaved if needed. A
lateral thigh post, positioned at
the level of the tourniquet, can
help to stabilize the knee when
it is placed in flexion with the
aid of a bump placed under the
foot and taped securely to the
table.
Approach and Exposure
After positioning, the extremity
is prepared and draped. With
the knee in extension, a straight
midline incision is planned.
The knee is then hyperflexed,
and a straight midline incision
is made starting approximately
5 to 10 cm proximal to the superior pole of the patella and
continuing an equal distance
distal to its inferior pole. The
incision is carried down to
the deep fascial layer to expose
the quadriceps tendon, vastus
medialis obliquus, patella, and
patellar tendon. Undermining
of the skin flaps is avoided. A
standard medial arthrotomy is
made.
The medial soft tissues are
released subperiosteally from
the proximal part of the tibia
FIG. 8
Schematic of a valgus deformity before the “inside-out” release. Note the trapezoidal extension gap.
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foot on the previously installed
bump.
Tibial Resection
The proximal portion of the
tibia should be resected at 90° to
its long axis. The exact level of
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resection will vary, depending
on the preoperative evaluation
of the deformity and ligamentous laxity. In type-II valgus deformities, one should remember
to resect less bone than normal,
i.e., generally, 6 to 8 mm should
FIG. 9
Schematic after release of the posterolateral capsule and “pie-crusting” of the iliotibial
band. Note the symmetrical extension gap. LCL = lateral collateral ligament, and PCL =
posterior cruciate ligament.
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be resected from the medial
side. Before the tibial cuts are
made, alignment should be confirmed with the alignment
guide. The distal portion of the
alignment device should align
with the center of the talus on
the anteroposterior radiograph.
On the lateral radiograph, the
alignment rod should run parallel with the tibial crest. Once the
cutting jig is secured in place,
the proximal tibial resection is
performed.
Next, the trial tibial inset is
used to determine the size of
the tibial tray needed on the
basis of the anteroposterior
diameter of the lateral condyle.
An alignment rod is used to
check the alignment of the cut
tibial surface once again (Fig.
5). One should remember that,
when using this technique, a
varus tibial cut causes the femoral component to be internally rotated during the flexion
gap evaluation.
Femoral Resection
The femoral canal is first entered with use of a gouge to assist in drill passage. The entry
point is the intersection of the
patellofemoral and the tibiofemoral articular surfaces on the
lateral and medial femoral
condyles. The canal should be
entered with a drill, and then
the entry point should be enlarged by rotating the drill before sinking it completely. With
a correct entry point, the drill
should not come into contact
with the cortices of the femoral
shaft.
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Next, the intramedullary
femoral rod is inserted into the
hole and a femoral cutting jig is
aligned with the distal aspect of
the femur. The valgus angle with
the appropriate “right” or “left”
designation is set and placed on
the front of the locating device.
With a valgus knee, the jig is set
to cut in 3° of valgus to compensate for metaphyseal-diaphyseal
valgus remodeling that has usually taken place and to avoid undercorrection of the underlying
deformity (Fig. 6).
The cutting block is then
rotated until it is roughly parallel to the cut surface of the tibia
with the knee in 90° of flexion.
The anterior rough cut is made,
and then the distal femoral cut
is made, resecting no more
than 10 mm of bone from the
medial side while only removing 1 to 2 mm from the lateral
side.
At this point, the knee is
extended and a spacer block is
placed into the extension gap.
The limb is exsanguinated, and
the tourniquet is inflated. The
patella is then prepared for
resurfacing.
Evaluation of the
Extension Gap
Attention can now be directed
to the extension gap. With an
appropriately sized spacer block
in place, the mediolateral stability of the knee is evaluated in
full extension by applying both
a varus and a valgus stress (Fig.
7). The application of stress
should demonstrate lateral side
soft-tissue tightness in an un-
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FIG. 10
A spacer block is placed in the extension gap.
balanced valgus knee. Next, a
lamina spreader is placed cen-
trally in the gap. If the knee is
unbalanced, this should mani-
FIG. 11
Applying a varus stress. Note the opening on the lateral side.
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CRITICAL CONCEPTS | continued
PITFALLS:
• With this technique, a varus
tibial cut can lead to internal
rotation of the femoral
component.
• While performing the “insideout” release of the posterior
capsule, one should use
electrocautery to avoid iatrogenic injury to the peroneal
nerve.
• While pie-crusting of the iliotibial band is performed,
caution should be taken to
avoid puncturing through the
skin on the lateral side of
the knee.
FIG. 12
• The surgeon should ensure
that the knee is indeed balanced in extension before assessing the flexion gap.
Applying a valgus stress. Note the equal amount of opening on the medial side. This
knee is balanced.
continued
sary to fractionally lengthen the
lateral side (Figs. 8 and 9).
FIG. 13
Preliminary placement of the anteroposterior cutting block on the distal aspect of the femur.
fest as a trapezoidal gap. The
goal is to achieve a rectangular
extension gap. When the gap
is trapezoidal, soft-tissue
balancing with use of the
“inside-out” technique is neces-
The Steps of the “Inside-Out”
Technique
1. Remove peripheral
osteophytes.
2. Extend the knee and
distract with a lamina spreader.
3. Irrigate and dry the joint.
4. Palpate the posterior
cruciate ligament, posterolateral corner, and iliotibial band
with a finger or with a small
Cobb elevator to determine
tight structures.
5. Release any remnant of
the posterior cruciate ligament.
6. Release the posterolateral capsule intra-articularly
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with use of electrocautery at the
level of the tibial cut surface
from the posterior cruciate ligament to the posterior border of
the iliotibial band. (Electrocautery is used to avoid injury to the
peroneal nerve, which is usually
located <1 cm from the articular side.)
7. Preserve the popliteus if
possible, unless it is too tight.
8. The iliotibial band is
lengthened as necessary from the
inside with multiple transverse
stab incisions a few centimeters
proximal to the joint line with
use of the so-called pie-crusting
technique2.
9. Repeat these steps
after manual stress-testing if
necessary.
The knee should now be
balanced in extension. The application of a varus and valgus
stress to the knee with a spacer
block in place should allow for
a “springy” give of 2 to 3 mm
on both the medial and lateral
sides (Figs. 10, 11, and 12). The
retention of at least one or two
of the lateral stabilizers is important for stability. If instability is detected after the releases
have been performed, then use
of a constrained component is
considered.
Evaluation of the
Flexion Gap
Once the knee is balanced in extension, the flexion gap can be
addressed. One should not attempt flexion gap balance until
the extension gap has been balanced. One should remember
that overrelease of the medial
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FIG. 14
Evaluation of the flexion gap with a lamina spreader.
side can lead to internal rotation of the femoral component
with use of this technique.
The knee is placed in 90° of
FIG. 15
Evaluation of the flexion gap with a spacer block in place.
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FIG. 16
Intraoperative view of the knee after all bone cuts have been made.
flexion, and an anteroposterior
cutting block of the same size as
the tibial component is prelimi-
narily fixed to the distal aspect
of the femur roughly parallel to
the cut tibial surface (Fig. 13).
JBJS . ORG
(Bone cuts are used to balance
the knee in flexion, whereas
controlled soft-tissue lengthening is used to balance the
knee in extension.) A lamina
spreader is placed into the flexion gap, and the medial and lateral flexion gaps are measured
(Fig. 14). If the gaps are unequal, the block can be rotated
and/or raised or lowered to create a symmetric gap. The size of
the gap should be the same as
the extension gap or even 2 mm
less. The same spacer block that
was used in the extension gap
can be placed into the flexion
gap, prior to cutting the posterior condyles, to assess flexion
stability. It should create a snug
fit with no visible medial or lateral opening during internal and
external rotation of the leg (Fig.
15). If, at any time, rotational
malalignment is suspected, alignment can be checked by referencing the cutting block with respect
CRITICAL CONCEPTS | continued
AUTHOR UPDATE:
Many different surgical techniques and approaches have been
described for correcting the valgus
knee2-17. However, the results are
generally inferior and the complication rates are generally higher
when correcting a valgus deformity compared with its varus
counterpart.
These outcomes are due, in part, to
the technically demanding nature of
soft-tissue balancing in the valgus
knee. This, in turn, has led some
surgeons to accept the use of constrained implants when instability
could not be prevented with balancing techniques alone. Other surgeons have promoted medial
collateral ligament tightening reconstructions or lateral parapatellar approaches to deal with these
inherent instabilities. It is our opinion that these techniques are not
only unnecessary but also technically difficult and fraught with the
potential for wound and extensor
mechanism complications.
In an effort to deal with these issues, the technique described
herein was adopted by the senior
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author (C.S.R.) in 1985 to addres
inherent instabilities noted with his
earlier technique, originally described in 1979, with the total
condylar knee replacement1,2,9,18.
With use of the “inside-out” technique and the PFC Sigma posterior
stabilized total knee system (DePuy
Orthopaedics, Warsaw, Indiana), no
problems with late-onset instability
or neurovascular injury have been
noted (Figs. 17 through 20). Therefore, we recommend this technique
for the correction of all valgus type-I
and II deformities.
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FIG. 17
FIG. 18
Clinical photograph of a bilateral valgus deformity before
total knee replacement.
Clinical photograph of a bilateral valgus deformity after total
knee replacement with use of the “inside-out” technique.
to the anteroposterior axis of
Whiteside or the transepicondylar axis3.
The final anterior and posterior flexion cuts can now be
made. Box and chamfer cuts can
then be made allowing for lateralization of the femoral component (Fig. 16). Trial components
can be inserted to test the knee
for stability through a full range
of motion and for adequate patellar tracking.
Maltracking of the patella
should first be assessed with the
tourniquet deflated. If the components are well aligned and a
release is deemed necessary,
pie-crusting of the lateral retinaculum usually suffices and
avoids the complications of performing a full longitudinal lateral release.
The knee is irrigated and
the bone is dried. The components are cemented into place.
Excess cement is removed during pressurization, and the ce-
JBJS . ORG
ment is allowed to polymerize.
The capsule is closed in flexion
over a drain.
Postoperative Management
The patient is evaluated closely
for any signs of peroneal nerve
compromise. If any sign of nerve
compromise develops, the knee
is placed in flexion. If the compromise does not improve, the
bandage is then loosened. Physical therapy and continuous passive motion are initiated on the
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FIG. 20
Radiograph after total knee replacement with a PFC Sigma
posterior stablized fixed-bearing design.
FIG. 19
Radiograph of a valgus deformity before total knee replacement.
first postoperative day after the
drain has been removed. Patients are progressed to weightbearing as tolerated.
Amar S. Ranawat, MD
Chitranjan S. Ranawat, MD
Mark Elkus, MD
Vijay J. Rasquinha, MD
Roberto Rossi, MD
Sushrut Babhulkar, MD
Department of Orthopedic Surgery, Lenox Hill Hospital, 130 East 77th Street, William Black Hall,
11th Floor, New York, NY 10021. E-mail address
for A.S. Ranawat: [email protected]
The authors did not receive grants or outside funding in support of their research or preparation of
this manuscript. One or more of the authors
received payments or other benefits or a commitment or agreement to provide such benefits from a
commercial entity (C.S. Ranawat is a consultant
for DePuy). No commercial entity paid or directed,
or agreed to pay or direct, any benefits to any
research fund, foundation, educational institution, or other charitable or nonprofit organization
with which the authors are affiliated or associated.
The line drawings in this article are the work of
Joanne Haderer Müller of Haderer & Müller
([email protected]).
doi:10.2106/JBJS.E.00308
REFERENCES
1. Ranawat CS, editor. Total-condylar knee ar-
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throplasty: technique, results, and complications. New York: Springer; 1985.
2. Miyasaka KC, Ranawat CS, Mullaji A. 10to 20-year follow-up of total knee arthroplasty for valgus deformities. Clin Orthop
Relat Res. 1997;345:29-37.
S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 ·
modified lateral capsular approach with repositioning of vastus lateralis. J Bone Joint Surg
Br. 1998;80:859-61.
8. Mihalko WM, Krackow KA. Anatomic and
biomechanical aspects of pie crusting posterolateral structures for valgus deformity
correction in total knee arthroplasty: a cadaveric study. J Arthroplasty. 2000;15:
347-53.
3. Whiteside LA. Correction of ligament and
bone defects in total arthroplasty of the severely valgus knee. Clin Orthop Relat Res.
1993;288:234-45.
4. Whiteside LA. Selective ligament release
in total knee arthroplasty of the knee in
valgus. Clin Orthop Relat Res. 1999;367:
130-40.
5. Krackow KA, Mihalko WM. Flexion-extension joint gap changes after lateral structure
release for valgus deformity correction in total knee arthroplasty: a cadaveric study. J Arthroplasty. 1999;14:994-1004.
6. Healy WL, Iorio R, Lemos DW. Medial reconstruction during total knee arthroplasty for
severe valgus deformity. Clin Orthop Relat
Res. 1998;356:161-9.
7. Fiddian NJ, Blakeway C, Kumar A. Replacement arthroplasty of the valgus knee. A
9. Insall JN, Scott WN, Ranawat CS. The total
condylar knee prosthesis. A report of two
hundred and twenty cases. J Bone Joint Surg
Am. 1979;61:173-80.
10. Scott DS, Thornhill TS, Ranawat CS.
Surgical technique for use with PFC Sigma
Knee Systems. DePuy Orthopedics; Warsaw,
IN: 1998.
11. Keblish PA. The lateral approach to the
valgus knee. Surgical technique and analysis
of 53 cases with over two-year follow-up
evaluation. Clin Orthop Relat Res. 1991;271:
52-62.
12. Krackow KA, Jones MM, Teeny SM, Hungerford DS. Primary total knee arthroplasty in
patients with fixed valgus deformity. Clin Or-
JBJS . ORG
thop Relat Res. 1991;273:9-18.
13. Karachalios T, Sarangi PP, Newman JH.
Severe varus and valgus deformities treated
by total knee arthroplasty. J Bone Joint Surg
Br. 1994;76:938-42.
14. Stern SH, Moeckel BH, Insall JN. Total
knee arthroplasty in valgus knees. Clin Orthop Relat Res. 1991;273:5-8.
15. Laurencin CT, Scott RD, Volatile TB, Gebhardt EM. Total knee replacement in severe
valgus deformity. Am J Knee Surg.
1992;5:135.
16. Buechel FF. A sequential three-step lateral release for correcting fixed valgus knee
deformities during total knee arthroplasty.
Clin Orthop Relat Res. 1990;260:170-5.
17. Aglietti P, Buzzi R, Giron F, Zaccherotti G.
The Insall-Burstein posterior stabilized total
knee replacement in the valgus knee. Am J
Knee Surg. 1996;9:8-12.
18. Ranawat CS, Rose HA, Rich DS. Total
condylar knee arthroplasty for valgus
and combined valgus-flexion deformity of
the knee. Instr Course Lect. 1984;33:
412-6.
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The PDF of the article you requested follows this cover page.
Surgical Management of Trapezius Palsy
F. Teboul, P. Bizot, R. Kakkar and L. Sedel
J Bone Joint Surg Am. 87:285-291, 2005. doi:10.2106/JBJS.E.00496
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COPYRIGHT © 2005
BY
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OF
BONE
AND JOINT
SURGERY, INCORPORATED
Surgical Management
of Trapezius Palsy
Surgical Technique
By F. Teboul, MD, MS, P. Bizot, MD, MS, R. Kakkar, MD, MS, and L. Sedel, MD
Investigation performed at the Department of Orthopaedics, Hôpital Lariboisière, Paris, France
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 1884-1890, September 2004
INTRODUCTION
The clinical features of trapezius palsy include pain, loss of shoulder
abduction, and winging of the scapula. Surgical biopsy of lymph nodes
is the main cause of the palsy.
The surgical technique (nerve repair or palliative surgery) depends on the etiology, the time since the onset of the palsy, and the patient characteristics.
SURGICAL TECHNIQUE
Nerve Surgery
The procedure is performed with the patient under general anesthesia. The patient is placed in the supine position, with his or her head
turned to the contralateral side and fixed in that position. The cervical area, including the whole upper limb, is draped to allow for easy
manipulation of the extremity. The ipsilateral lower limb is also
draped to allow for the harvesting of a free sural nerve graft, if
needed. The incision incorporates previous incisions and is extended on both ends to create a z-shaped incision, 2 cm behind the
posterior border of the sternocleidomastoid and the trapezius bulge.
The first step in the dissection is to expose the posterior margin of
the sternocleidomastoid and the anterior margin of the trapezius
muscles. The great auricular nerve is identified as it wraps around
the posterior margin of the sternocleidomastoid. Then the proximal
part of the spinal accessory nerve is identified, with the dissection being extended to the anterior margin of the sternocleidomastoid if
necessary. The distal part of the spinal accessory nerve is then exposed close to the fascia of the trapezius. If the nerve is in continuity,
intraoperative stimulation is performed at 0.2 mA with an electrostimulator. If a response is obtained distally with a trapezius muscle
contraction, only an extrafascicular neurolysis is performed. OtherDownloaded from www.ejbjs.org on September 3, 2005
ABSTRACT
BACKGROUND:
Injury to the spinal accessory
nerve in the posterior cervical
triangle leads to paralysis of the
trapezius muscle. The aim of
this study was to determine the
indications for nerve repair or reconstructive surgery according
to the etiology, the duration of
the preoperative delay, and specific patient characteristics.
METHODS:
Of twenty-seven patients with a
trapezius palsy, twenty were
treated with neurolysis or surgical repair (direct or with a graft)
of the spinal accessory nerve
and seven were treated with the
Eden-Lange muscle transfer procedure. Lymph node biopsy was
the main cause of the nerve injury. The nerve repairs were performed at an average of seven
months after the injury, and the
reconstructive procedures were
done at an average of twentyeight months. Nerve repair was
performed for iatrogenic injuries
of the spinal accessory nerve,
continued
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ABSTRACT | continued
within twenty months after the
onset of symptoms, and in one
patient with spontaneous palsy.
Reconstructive surgery was performed for cases of trapezius
palsy secondary to radical neck
dissection, for spontaneous palsies, and after failure of nerve
repair or neurolysis. The mean
follow-up period was thirty-five
months. The functional outcome was assessed clinically on
the basis of active shoulder abduction, pain, strength of the
trapezius on manual muscletesting, and level of subjective
patient satisfaction.
RESULTS:
The results were good or excellent
in sixteen of the twenty patients
treated with nerve repair and in
four of the seven patients treated
with the Eden-Lange procedure.
Poor results were seen in older
patients and in patients with a
previous radical neck dissection.
CONCLUSIONS:
Good results can be expected
from a repair of the spinal accessory nerve if it is performed
within twenty months after the
injury, as the nerve is basically a
purely motor nerve and the distance from the injury to the motor end plates is short. Muscle
transfer should be performed in
patients with spontaneous trapezius palsy, when previous
nerve surgery has failed, or
when the time from the injury
to treatment is over twenty
months. Treatment is less likely
to succeed when the patient is
older than fifty years of age or
the palsy was due to a radical
neck dissection, penetrating injury, or spontaneous palsy.
FIG. 1-A
Intraoperative photograph of the accessory nerve, made eleven months after the onset
of symptoms. A neuroma is seen in the proximal part of the nerve (on the right side of
the figure), with loss of nerve substance.
FIG. 1-B
A free single sural nerve graft is placed between the cut ends after normal fasciculi are
obtained under magnification.
wise, the nerve is transected, the
neuroma-in-continuity is resected, and the nerve ends are
trimmed until normal fasciculi
are obtained (as indicated by
neatly arranged fasciculi without surrounding fibrosis as seen
under the microscope). Then,
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an end-to-end suture or a repair
with use of a free single sural
nerve graft is performed (Figs.
1-A and 1-B), depending on the
tension in the nerve and on the
size of the gap between the nerve
ends. The nerve repair is performed under magnification
with 10-0 nylon suture. In the
case of free grafting, the donor
nerve is always the sural nerve.
The nerve is identified through a
short transverse incision at the
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level of the lateral malleolus.
With use of a second incision, 3
cm proximal to the first, the
nerve is again identified at this
level. With gentle traction, the
nerve, which may have two or
three branches at this level, can
be mobilized and each branch is
transected. It is then gently
pulled out at the level of the
proximal incision and, then,
with gentle traction applied to
the distal end, the course of the
JBJS . ORG
nerve is followed proximally up
to the middle part of the leg.
The nerve is exposed here and
transected. The three to five
small transverse incisions created with this technique are cosmetically quite acceptable.
The incision is closed in two
layers. Free active and passive
motion of the shoulder is allowed immediately. The patient
is allowed to leave the hospital on
the third postoperative day.
FIG. 2
In the Eden-Lange procedure, the levator scapulae, rhomboideus major, and rhomboideus minor muscles are transferred laterally.
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CRITICAL CONCEPTS
INDICATIONS (FIG. 6):
Nerve surgery can be attempted
between twelve and twenty months
after the nerve injury. If a contraction of the trapezius muscle is
obtained on intraoperative stimulation, a neurolysis should be
performed. When there is no contraction of the muscle during the intraoperative stimulation or when
there is complete transection of
the nerve, repair or grafting should
be performed, depending on the
age of the patient, the length of the
nerve gap after resection of the cut
ends, and the extent of local fibrosis. In our opinion, there is no indication for performing both a nerve
procedure and the muscle transfer
at the same time.
Palliative surgery should be pursued after failure of microsurgical
repair of the spinal accessory
nerve, in cases of spontaneous
palsy of the trapezius, after a
radical neck dissection, or when
more than twenty months have
elapsed since the injury.
CONTRAINDICATIONS:
There are no real contraindications. However, because of anatomical variation and because of
compensation by the levator scapulae, the clinical consequences of an
injury to the spinal accessory nerve
must be carefully evaluated in each
patient. Nonoperative treatment for
active patients is usually unsuccessful, although rehabilitation and
physiotherapy can reduce pain for
older and sedentary patients3.
Two significant factors were found
to be predictive of a poor result in
our study: a patient age of more
than fifty years and a spinal accessory nerve lesion caused by radical
neck dissection, penetrating injury, or spontaneous palsy.
continued
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Palliative Surgery:
The Eden-Lange Procedure
The triple transfer of the levator scapulae, rhomboideus major, and rhomboideus minor
muscles was originally described by Eden1 and later by
Lange2. The goal of this transfer
is to reconstruct the three parts
of the trapezius muscle. Because of their normal medial
insertions, these muscles are
incapable of stabilizing the
scapula in the presence of a trapezius palsy. Therefore, if they
are transferred laterally (Fig. 2),
through the traction exerted by
their contraction, the scapula
can be stabilized in a position
of abduction and anterior
flexion.
The patient is placed in the
lateral decubitus position with
the help of thoracic, pubic, and
sacral supports. The whole upper limb, including the shoul-
FIG. 3
Intraoperative photograph made during the Eden-Lange procedure. The
supraspinatus muscle is elevated 1
to 2 cm. The infraspinatus muscle is
elevated 2 to 3 cm. The rhomboid insertions are detached from the scapular periosteum, and the levator
scapulae insertion is detached along
with a small piece of bone from the
superomedial angle of the scapula.
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der girdle, is draped free. A
continuous incision is made,
starting from the spine of the
scapula, continuing along its
medial angle and spinal border,
and terminating 2 cm proximal
to its inferior angle. The trapezius is incised and retracted.
Then, the levator scapulae,
rhomboideus major, and rhomboideus minor are dissected and
are marked with a linen tape.
The supraspinatus muscle is elevated 1 to 2 cm. The rhomboid
insertions are detached from the
scapular periosteum, and the
levator scapulae insertion is detached along with a small piece
of bone from the superomedial
angle of the scapula with use of
an oscillating saw (Fig. 3). The
infraspinatus muscle is also elevated, 2 to 3 cm. Then, the
rhomboids are advanced 3 cm
laterally and are fixed to the
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CRITICAL CONCEPTS | continued
PITFALLS:
• The preparation of the nerve ends
is a very important step of the operation. In a case of complete sectioning or loss of nerve tissue, a
neuroma will have developed on the
proximal stump of the spinal accessory nerve. The neuroma has to be
resected, and both nerve ends have
to be prepared. Segments of each
nerve stump are resected, with use
of a sharp knife, until normal nerve
tissue is reached.
proceeds with accurate placement
of the suture in the epineurium but
not into the substance of the nerve
fascicle itself. The appropriate tension is achieved when the underlying fascicles have been coapted but
the ends are not overlapping or
malaligned. Three to five sutures
usually are sufficient to achieve appropriate repair of the spinal accessory nerve. At the completion of a
successful repair, the epineurium
should be closed, without herniation of fascicular tissue between
the sutures.
• To suture a free single nerve graft,
the technique of epineurial repair
is used. The epineurial repair
continued
scapular body with nonabsorbable, transosseous sutures. The
superior surface of the prominent portion of the scapular
spine (before it transforms into
the acromion) is decorticated,
and the levator scapulae with its
osseous fragment is fixed there
with number-3, 8, or 10 stainless steel transosseous sutures
FIG. 4
Intraoperative photograph made
during the Eden-Lange procedure.
The rhomboids are advanced 3
cm laterally and are fixed to the
scapular body with nonabsorbable, transosseous sutures. The
superior surface of the bulging
portion of the scapular spine (before it transforms into the acromion) is decorticated, and the
levator scapulae with its osseous
fragment is fixed there with
number-3, 8, or 10 stainless
steel transosseous sutures. The
infraspinatus is then sutured
back to cover the new rhomboid
insertion.
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FIG. 5
Postoperative radiograph made after the
Eden-Lange procedure. The levator scapulae muscle with its osseous fragment is
fixed to the superior surface of the bulging portion of the scapular spine with use
of number-3, 8, or 10 stainless steel transosseous sutures.
- Spontaneous palsy
Symptomatic trapezius palsy
- Previous radical neck dissections
- Preoperative delay >20 months
Preoperative delay <20 months
<12 months
Neurolysis or
nerve graft
Eden-Lange procedure
12< >20 months
Exploration and intraoperative
stimulation
Negative
Positive distal response
Neurolysis
Nerve surgery or reconstruction
depending on:
- Age
- Preoperative delay
FIG. 6
- Nerve gap size
The recommended algorithm defining a strategy for the treatment of trapezius palsy.
- Local fibrosis
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layers with two suction drains
in place.
The limb is immobilized
with a bandage that secures the
arm to the chest for six weeks.
From the sixth week onward,
gentle active and passive exercises
are started.
CRITICAL CONCEPTS | continued
AUTHOR UPDATE:
In the original study, one patient
with a spontaneous palsy was
managed with a simple neurolysis because a trapezius muscle
contraction was obtained during
intraoperative stimulation. The
result, however, was very poor,
with no recovery of trapezius
function. In cases of spontaneous palsy, we now perform only
reconstructive surgery with muscle transfers.
JBJS . ORG
provide such benefits from a commercial entity.
No commercial entity paid or directed, or agreed
to pay or direct, any benefits to any research fund,
foundation, educational institution, or other charitable or nonprofit organization with which the
authors are affiliated or associated.
The line drawings in this article are the work of
Jennifer Fairman
([email protected]).
doi:10.2106/JBJS.E.00496
F. Teboul, MD, MS
10 rue d’Alsace, 92300, Levallois-Perret, France.
E-mail address: [email protected]
(Figs. 4 and 5). The infraspinatus is then sutured back to cover
the new rhomboid insertion,
and the incision is closed in
P. Bizot, MD, MS
R. Kakkar, MD, MS
L. Sedel, MD
Hôpital Lariboisière, 2 rue Ambroise Paré, Paris
75010, France
The authors did not receive grants or outside funding in support of their research or preparation of
this manuscript. They did not receive payments or
other benefits or a commitment or agreement to
REFERENCES
1. Eden R. Zur behandlung der trapeziuslähmung mittelst muskelplastik. Deutsche
Zeitschr Chir. 1924;184:387-97.
2. Lange M. [Treatment of paralysis of the trapezius]. Langenbecks Arch Klin Chir Ver
Dtsch Z Chir. 1951;270:437-9. German.
3. Pelissier J, Lopez S, Herisson C, Lallemand JG, Guerrier B, Simon L. [Shoulder pain
and trapezius paralysis. Evaluation of a rehabilitation protocol]. Rev Rhum Mal Osteoartic.
1990;57:319-21. French.
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Clinical and Radiographic Results of Expansive Lumbar Laminoplasty
in Patients with Spinal Stenosis
Yoshiharu Kawaguchi, Masahiko Kanamori, Hirokazu Ishihara, Tasuku Kikkawa, Hisao Matsui, Haruo Tsuji and
Tomoatsu Kimura
J Bone Joint Surg Am. 87:292-299, 2005. doi:10.2106/JBJS.E.00211
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292
COPYRIGHT © 2005
BY
THE JOURNAL
OF
BONE
AND JOINT
SURGERY, INCORPORATED
Clinical and Radiographic
Results of Expansive Lumbar
Laminoplasty in Patients
with Spinal Stenosis
Surgical Technique
By Yoshiharu Kawaguchi, MD, Masahiko Kanamori, MD, Hirokazu Ishihara, MD, Tasuku Kikkawa, MD,
Hisao Matsui, MD, Haruo Tsuji, MD, and Tomoatsu Kimura, MD
Investigation performed at the Department of Orthopaedic Surgery, Toyama Medical and Pharmaceutical University, Toyama, Japan
The original scientific article in which the surgical technique was presented was published in JBJS Vol. 86-A, pp. 1698-1703, August 2004
ABSTRACT
BACKGROUND:
In 1981, we developed a technique of expansive lumbar
laminoplasty to alleviate the
problems of conventional laminectomy in the treatment of spinal stenosis. The purposes of
this study were to assess the
long-term outcome following expansive lumbar laminoplasty
and to investigate the postoperative problems.
METHODS:
Fifty-four patients underwent expansive lumbar laminoplasty for
the treatment of spinal stenosis.
There were forty-three men and
eleven women with a mean age
of 52.6 years. The average
continued
INTRODUCTION
Decompressive laminectomy has been widely used for the treatment
of lumbar spinal stenosis. However, iatrogenic instability following
laminectomy sometimes occurs in patients with degenerative or
spondylolisthetic spinal stenosis. Furthermore, the so-called laminectomy membrane, representing epidural scar in the spinal canal, might
result in unfavorable sequelae after removal of the laminae. To avoid
these problems, the technique of expansive lumbar laminoplasty was
developed in 1982. In this report, we describe the technical details of
this procedure, surgical indications, and pitfalls.
SURGICAL TECHNIQUE
The original surgical technique of expansive lumbar laminoplasty
was described by Tsuji et al.1-5. The step-by-step procedure is described
below.
1. A groove is created in the laminae. After the spinous processes
of the target laminae are removed, the laminae are cut with use of a
high-speed air drill.
2. A tunnel is made for wire passage (Fig. 1). Just prior to mobilization of the laminae, small holes are made in each lamina on the side
to be opened. The holes pass from the area of the removed spinous
process to the groove and from the groove to the lateral surface of the
laminae.
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ABSTRACT | continued
length of follow-up was 5.5
years. Preoperatively, twentyfive patients had degenerative
stenosis; thirteen, stenosis
due to spondylolisthesis;
twelve, combined stenosis (disc
herniation and stenosis); and
six, hyperostotic stenosis.
(Two patients with hyperostotic
stenosis and spondylolisthesis
were included in both groups.)
The clinical results were assessed with use of the Japanese Orthopaedic Association
score, and the rate of recovery
was calculated. Radiographic
findings were analyzed on the
basis of the cross-sectional
area of the spinal canal, kyphosis, range of motion of the
lumbar spine, and the rate of
interlaminar fusion.
RESULTS:
FIG. 1
Tunnel-making technique. Small holes are made in each lamina and the articular process on the open side with use of an awl, pusher, and perforator.
3. The wire is passed
through the holes. A 0.3-mm
braided steel wire, a 0.4-mm
monofilament steel wire, or a
number-1 braided nylon suture
is passed through the holes of
the lamina.
4. Rotatory elevation of the
lamina and intraspinal interven-
tion are performed (Fig. 2). The
laminae are completely detached
along the groove on the side to
be opened with use of a diamond burr, and the ligamentum
flavum is also dissected free on
the same side with a knife. On
the hinged side, an incomplete
separation of the laminae is
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The average recovery rate at
the time of the last follow-up
was 69.2% for patients with
degenerative stenosis, 66.5%
for patients with combined
stenosis, 65.2% for those with
hyperostotic stenosis, and
54.7% for those with spondylolisthesis. The factors resulting in a poor recovery were an
older age and insufficient decompression of the lateral
stenosis. During the follow-up
period, the Japanese Orthopaedic Association score became worse for seven patients,
six patients had lesions develop at the level adjacent to
the laminoplasty, and five patients had spondylolisthesis
develop. Interlaminar fusion
was observed in twenty-two
patients (41%).
continued
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FIG. 2
Rotatory elevation of the lamina and intraspinal intervention. The laminae on the side to
be opened are cut completely, and then the
laminae are rotated to an angle of at least 45°.
The edge of the groove facing the lateral recess of the spinal canal is trimmed with use of
a rongeur.
FIG. 3
Wiring technique. From the open side, the wire
or nylon suture is passed through the holes in
the lamina, the bone graft, and the articular
process and then is firmly tightened.
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ABSTRACT | continued
CONCLUSIONS:
The satisfactory results of expansive lumbar laminoplasty
were maintained at an average
of 5.5 years after surgery. The
best indications for the lumbar
laminoplasty procedure were
young and active patients with
central spinal stenosis.
created by means of interrupted
perforations of the internal cortex with use of a diamond burr.
Then, the laminae are turned up
to an angle of at least 45°. The
undersurface of the groove facing the lateral recess of the spinal
CRITICAL CONCEPTS
INDICATIONS:
• Multilevel degenerative spinal
stenosis accompanied by developmental spinal stenosis in
physically active patients
• Multilevel combined stenosis
accompanied by lumbar disc
herniation or intraspinal ossified lesions
• Multilevel degenerative spinal
stenosis with instability of the
lumbar segments when reinforcement of the instability is
required
• Intraspinal tumors in young
patients
FIG. 4-A
Figs. 4-A, 4-B, and 4-C Bone-grafting technique. Fig. 4-A After completion of the wiring,
cancellous bone graft is harvested from the iliac crest and is placed on the hinged side.
All of the open epidural spaces between the laminae should be shielded by free fat grafting. When a posterior spinal arthrodesis is performed, the joint capsules are completely
removed and the laminae and the articular processes are decorticated bilaterally with
use of a high-speed air drill.
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CONTRAINDICATIONS:
• Lateral stenosis due to
degenerative scoliosis or
spondylolisthesis
• Lateral lumbar disc herniation
• Elderly patients, i.e., those
who are more than seventy
years old
continued
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FIG. 4-B
Strips of corticocancellous bone from the posterior aspect of the ilium are carefully applied.
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CRITICAL CONCEPTS | continued
PITFALLS:
• Bleeding can be extensive
with this procedure, and preoperatively we try to have the
patient donate 400 to 800
mL of autologous blood for
transfusion.
FIG. 4-C
The spinal canal is expanded into a rectangular shape in cross section.
• When the grooves are made in
the laminae, the spinous process should be removed carefully at its base and preserved
for use as a bone graft, the
outer edge of the groove
should reach the lateral onethird of the articular facets,
and the groove on the hinged
side should be wider and more
conical than the groove on the
open side in order to obtain
sufficient rotation of the laminae (Fig. 5).
• A special awl, pusher, and perforator are used for making the
tunnels (Fig. 6).
• The entrance to each drill-hole
should be widened with use of
a high-speed air drill to facilitate easy passage of the wire
or thread.
• During rotatory elevation of
the lamina, the internal cortex on the hinged side should
not be completely removed. If
there is a possibility of the
lamina becoming depressed
into the spinal canal on the
hinged side, the wires should
be passed before the lamina
is rotated.
FIG. 5
Groove-making technique. The groove on the hinged side should be wider and more
conical than the groove on the open side in order to allow sufficient rotation of the
laminae.
• If the amount of the graft
obtained from the spinous
processes is not enough, corticocancellous bone from the
posterior aspect of the ilium is
obtained.
continued
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FIG. 6
Special instruments (Tanaka Medical, Tokyo, Japan) for expansive lumbar laminoplasty include awls with different angles (A), a pusher (B),
and perforators (C).
canal is trimmed with a rongeur
and curet, and the remaining ligCRITICAL CONCEPTS | continued
PITFALLS (CONTINUED):
• Decortication of the surface
of the laminae must be performed carefully.
• Postoperatively, a cast or hard
brace is applied and worn for up
to one month after surgery and
then a soft brace is recommended for two additional
months.
continued
amentum flavum is removed as
completely as possible.
5. The spinous processes are
trimmed to make bone grafts
and bone chips. The spinous
processes are reformed into
cubes measuring 15 to 20 mm by
10 to 15 mm and are used for
bone graft. A transverse hole is
made in each graft. Any
remaining bone is used to make
bone chips.
6. The wire is inserted, and
the opened rotated laminae are
fastened (Fig. 3). The wire or the
nylon suture is passed through
the holes in the lamina, the bone
graft, and the articular process.
The wire or suture is firmly
tightened after the bone graft is
interposed into the gap on the
open side.
7. Bone graft and fat-tissue
graft are inserted (Figs. 4-A,
4-B, and 4-C). After completion
of the wiring, the hinged side
of the laminae, including the articular processes, is thoroughly
decorticated with a power drill
and bone chips or corticocan-
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Yoshiharu Kawaguchi, MD
Masahiko Kanamori, MD
Hirokazu Ishihara, MD
Tasuku Kikkawa, MD
Haruo Tsuji, MD
Tomoatsu Kimura, MD
Department of Orthopaedic Surgery, Toyama
Medical and Pharmaceutical University, Faculty
of Medicine, 2630 Sugitani, Toyama 930-0194,
Japan. E-mail address for Y. Kawaguchi:
[email protected]
CRITICAL CONCEPTS | continued
AUTHOR UPDATE:
We have found that lateral recess decompression within the
spinal canal can be performed
on the hinged side. If there is a
symptomatic lumbar disc herniation, discectomy can be performed through the open gap.
Intraspinal tumors can also be
removed through the open gap.
Hisao Matsui, MD
Division of Orthopaedic Surgery, Takaoka City
Hospital, 4-1, Takaramachi, Takaoka, 933-8550
Toyama, Japan
cellous strips of bone harvested
from the iliac crest are applied
over the decorticated area. Free
fat tissue is placed in the epidural spaces, which are open between the laminae.
8. After a suction drain is
placed, the wound is closed.
The authors did not receive grants or outside
funding in support of their research or preparation of this manuscript. They did not receive
payments or other benefits or a commitment or
agreement to provide such benefits from a commercial entity. No commercial entity paid or
directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or
nonprofit organization with which the authors
are affiliated or associated.
JBJS . ORG
The line drawings in this article are the work of
Joanne Haderer Müller of Haderer & Müller
([email protected]).
.
doi:10.2106/JBJS.E.00211
REFERENCES
1. Tsuji H. Laminoplasty for patients with
compressive myelopathy due to so-called spinal canal stenosis in cervical and thoracic regions. Spine. 1982;7:28-34.
2. Tsuji H. Comprehensive atlas of lumbar
spine surgery. St. Louis: Mosby Year Book;
1991. Expansive laminoplasty. p 116-9.
3. Tsuji H, Itoh T, Sekido H, Yamada H, Katoh
Y, Makiyama N, Yamagami T. Expansive laminoplasty for lumbar spinal stenosis. Int Orthop. 1990;14:309-14.
4. Matsui H, Tsuji H, Sekido H, Hirano N, Katoh
Y, Makiyama N. Results of expansive laminoplasty for lumbar spinal stenosis in active manual workers. Spine. 1992;17(3 Suppl):S37-40.
5. Matsui H, Kanamori M, Ishihara H, Hirano
N, Tsuji H. Expansive lumbar laminoplasty for
degenerative spinal stenosis in patients below 70 years of age. Eur Spine J.
1997;6:191-6.
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