Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
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. This is an enhanced PDF from The Journal of Bone and Joint Surgery The PDF of the article you requested follows this cover page. 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 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 Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 149 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 150 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 151 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S FIG. 1-B S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 152 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 153 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 JBJS . ORG 154 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 155 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 JBJS . ORG 156 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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), S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 157 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 158 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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. S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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- JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 159 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 continued 160 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 161 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S FIG. 6-B S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 162 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 163 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 164 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 165 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. 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. 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 article, or locate the article citation on jbjs.org and click on the [Reprints and Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 166 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. Downloaded from www.ejbjs.org on September 3, 2005 167 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 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. 168 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S FIG. 3 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 Downloaded from www.ejbjs.org on September 3, 2005 JBJS . ORG 169 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S FIG. 6-A S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 170 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S FIG. 6-C S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 FIG. 6-E Intraoperative photograph showing an eburnated proximal pole of the scaphoid (arrow). 171 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 172 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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). Downloaded from www.ejbjs.org on September 3, 2005 173 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 174 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 175 COPYRIGHT © 2005 BY THE JOURNAL OF 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. Downloaded from www.ejbjs.org on September 3, 2005 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 176 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 177 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 178 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 179 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 180 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · FIG. 9 Medial and lateral sleeves have been created, allowing direct exposure to the implants and the anterior aspect of the tibia and tubercle. JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 181 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 182 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 183 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 184 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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, Downloaded from www.ejbjs.org on September 3, 2005 185 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 186 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 JBJS . ORG 187 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 JBJS . ORG 188 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 189 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 190 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 191 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 192 THE JOURNAL OF FIG. 26-A B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 193 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 194 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. 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. 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 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 Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 195 COPYRIGHT © 2005 BY THE JOURNAL OF 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 Downloaded from www.ejbjs.org on September 3, 2005 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 196 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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. S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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- JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 197 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 198 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 199 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 200 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 201 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 202 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 203 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 204 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 205 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 206 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 207 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 208 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 209 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. JBJS . ORG FIG. 4-B This lateral radiograph shows somewhat less comminution than that seen in Figures 1 and 3. Downloaded from www.ejbjs.org on September 3, 2005 210 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 211 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 212 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S sistive exercises are not allowed until radiographic signs of healing have been established. S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 JBJS . ORG 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. 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. 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 article, or locate the article citation on jbjs.org and click on the [Reprints and Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 213 COPYRIGHT © 2005 BY THE JOURNAL OF 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 Downloaded from www.ejbjs.org on September 3, 2005 continued 214 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 215 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 216 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 217 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 218 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 219 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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- JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 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 220 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 221 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 222 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 223 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 224 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 225 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 JBJS . ORG 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. 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. 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 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 Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 226 COPYRIGHT © 2005 BY THE JOURNAL OF 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 Downloaded from www.ejbjs.org on September 3, 2005 227 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · FIG. 1 Coronal T1-weighted magnetic resonance image showing the preoperative extent of the femoral tumor. JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 228 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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. Downloaded from www.ejbjs.org on September 3, 2005 229 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 230 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 231 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 232 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 233 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 234 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 235 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 Downloaded from www.ejbjs.org on September 3, 2005 236 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. 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. 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 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 Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 237 COPYRIGHT © 2005 BY THE JOURNAL OF 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 Downloaded from www.ejbjs.org on September 3, 2005 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 continued 238 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 239 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 JBJS . ORG 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 240 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S FIG. 3-A S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 241 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 242 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 243 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S FIG. 7-A S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · FIG. 7-B JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 244 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 245 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 246 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 JBJS . ORG 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. 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. 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 article, or locate the article citation on jbjs.org and click on the [Reprints and Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 247 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 Downloaded from www.ejbjs.org on September 3, 2005 continued 248 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S flex to 90°. The arthroscope is introduced through a high anterior arthroscopic portal, and the intra-articular structures are ex- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · amined; meniscal surgery is performed when needed. A 10mm-wide graft is taken from the central third of the patellar ten- JBJS . ORG 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). Downloaded from www.ejbjs.org on September 3, 2005 249 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 250 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 JBJS . ORG 251 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 252 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 253 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 254 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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° Downloaded from www.ejbjs.org on September 3, 2005 255 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 256 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 257 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 258 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 259 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 260 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 261 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 262 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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. S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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). JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 263 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 4. Insall JN, editor. Surgery of the knee. New York: Churchill Livingstone; 1984. p 384-7. S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. 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. 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 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 Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 264 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. Downloaded from www.ejbjs.org on September 3, 2005 265 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 266 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 Downloaded from www.ejbjs.org on September 3, 2005 267 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 268 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 269 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 270 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. 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. 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 article, or locate the article citation on jbjs.org and click on the [Reprints and Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 271 COPYRIGHT © 2005 BY THE JOURNAL OF 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 272 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 273 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 274 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 275 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 276 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 277 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 278 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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- S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 279 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 280 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 281 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 Downloaded from www.ejbjs.org on September 3, 2005 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. 282 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 Downloaded from www.ejbjs.org on September 3, 2005 283 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 284 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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. 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. 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 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 Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 285 COPYRIGHT © 2005 BY THE JOURNAL 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 286 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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, Downloaded from www.ejbjs.org on September 3, 2005 287 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 288 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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 JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 289 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S 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 S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 290 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 291 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. 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. 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 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 Permissions] link. Publisher Information The Journal of Bone and Joint Surgery 20 Pickering Street, Needham, MA 02492-3157 www.jbjs.org Downloaded from www.ejbjs.org on September 3, 2005 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. Downloaded from www.ejbjs.org on September 3, 2005 293 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 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 294 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005 JBJS . ORG 295 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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. Downloaded from www.ejbjs.org on September 3, 2005 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 296 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · FIG. 4-B Strips of corticocancellous bone from the posterior aspect of the ilium are carefully applied. Downloaded from www.ejbjs.org on September 3, 2005 JBJS . ORG 297 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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 Downloaded from www.ejbjs.org on September 3, 2005 298 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · JBJS . ORG 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- Downloaded from www.ejbjs.org on September 3, 2005 299 THE JOURNAL OF B O N E & J O I N T S U R G E R Y · S U R G I C A L TE C H N I Q U E S S EPTEMBER 2005 · VOLUME 87-A · S UPPLEMENT 1, P AR T 2 · 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. Downloaded from www.ejbjs.org on September 3, 2005