Chapter 30 Orthopedic Surgery Orthopedic Surgery Review terms

Chapter 30 Orthopedic Surgery

Orthopedic Surgery Review terms and definitions listed at beginning of chapter Use your medical dictionary if necessary Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 2

Orthopedic Surgery Bone tissue Cortical (compact) found on the surface of bones Ø Cancellous (spongy) found on the end of bones and the inner layer Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 3

Orthopedic Surgery Flat bone, showing compant and cancellous layers, haversian system, and trabeculae (From Thibodeau GA, Patton KT: Anatomy and physiology, ed 6, St Louis, 2007, Mobsy) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 4

Orthopedic Surgery Ø Bone tissue and membranes (cont. ) • The medullary canal Red marrow – Found in the small spaces of the cancellous bone – Highly vascular Yellow marrow – Consists mainly of fat cells and connective tissue – Found in the medullary cavity of long bones Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 5

Orthopedic Surgery Anatomy of a long bone. (From Thibodeau G, Patton K: Anatomy and physiology, ed 6, St. Louis, Mosby, 2007. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 6

Orthopedic Surgery Bone membrane Ø Endosteum • Lines the inner channels of long bones and fills the interstitial spaces of cancellous bone and the Haversian canals • It initiates bone growth and provides nutritional substance to bones Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 7

Orthopedic Surgery Ø Bone landmarks • Crest • Spine • Condyle • Process • Tubercle • Tuberosity • Foramen • Sinus • Sulcus Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 8

Orthopedic Surgery The skeleton Ø Anterior view of a skeleton (From Thibodeau GA, Patton KT: Anatomy and physiology, ed 6, St Louis, 2007, Mosby. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 9

Orthopedic Surgery The skeleton (cont. ) Ø Posterior view of a skeleton (From Thibodeau GA, Patton KT: Anatomy and physiology, ed 6, St Louis, 2007, Mosby. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 10

Orthopedic Surgery Bone healing Inflammatory phase Ø Reparative phase Ø Remodeling Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 11

Orthopedic Surgery Joints Synarthrosis • Limited movement Ø Amphiarthrosis • Slight movement Ø Synovial or diarthrosis • Freely movable Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 12

Orthopedic Surgery Joints Ø Synovial joint • Consists of articulating bone ends and connective tissues that surround and bind them • Surrounding joint is a tough fibrous tissue called the joint capsule • Joint capsule is lined with a membrane called the synovial membrane Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 13

Orthopedic Surgery Ø Synovial Joint (From D Vidic B, Suarez FR: Photographic atlas of the human body, St Louis, Mosby. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 14

Orthopedic Surgery Joints Ø Nonsynovial • Immovable cartilaginous joint Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 15

Orthopedic Surgery Anatomical movement Hinge joint Ø Saddle Ø Gliding Ø Ball and socket Ø Pivot Ø Condyloid Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 16

Orthopedic Surgery Ligaments Ø Ligaments attach bones to each other, providing flexibility and strength to the skeletal structure Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 17

Orthopedic Surgery Muscles of the human body in anterior position. (From Thibodeau GA, Patton KT: Anthony's textbook of anatomy and physiology, ed 17, St Louis, 2003, Mosby. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 18

Orthopedic Surgery Muscles of the human body in posterior position. (From Thibodeau GA, Patton KT: Anthony's textbook of anatomy and physiology, ed 17, St Louis, 2003, Mosby. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 19

Orthopedic Surgery Diagnostic procedures X-rays Ø Magnetic resonance imaging (MRI) Ø Computed tomography (CT) Ø CT-angiogram Ø Ultrasound Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 20

Orthopedic Surgery Patient transport and transfer Patients may arrive in traction Ø Patients may have external fixators Ø Patients may have antishock garments Ø May need additional personnel to transfer patient to operating room (OR) table Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 21

Orthopedic Surgery Positioning Standard OR table Ø Orthopedic table (fracture table) • Jointed • Open design • Translucent supports Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 22

Orthopedic Surgery Orthopedic Table A, Orthopedic table used for procedures of the hip and femur. The open configuration use allows C-arm fluoroscope positioning. The hips may be distracted by adjusting the leg extensions. B, Patient in lateral position. (From Miller M et al: Orthopaedic surgical approaches, Philadelphia, 2008, Saunders. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 23

Orthopedic Surgery Hemostasis Monitored blood loss Ø Pneumatic tourniquet Ø Hemostatic agents Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 24

Orthopedic Surgery Infection control Particular attention paid to airborne contaminants and droplet contamination Ø Laminar airflow rooms with greater than 300 exchanges per minute Ø Use of ultraviolet lights Ø Use of “space suits” Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 25

Orthopedic Surgery Fractures Common fracture patterns. (From Thibodeau GA, Patton KT: Anthony's textbook of anatomy and physiology, ed 17, St Louis, 2003, Mosby. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 26

Orthopedic Surgery Fracture classification criteria Name of the bone location Ø Pattern of fracture Ø Level of communution Ø Displacement Ø Pathological origin Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 27

Orthopedic Surgery Fracture patterns Transverse Ø Oblique Ø Spiral Ø Impacted Ø Comminuted Ø Open fracture Ø Greenstick Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 28

Orthopedic Surgery Biomechanical forces Torsion or torque Ø Shear force Ø Axial force Ø Energy transfer Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 29

Orthopedic Surgery Reduction Ø Bringing the bone fragments into anatomical alignment Types of reduction Open reduction Ø Closed reduction Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 30

Orthopedic Surgery Fixation Ø Mechanical or structural method used to hold bone fragments together Types of fixation Internal fixation Ø External fixation Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 31

Orthopedic Surgery Surgical options for fixation Open reduction internal fixation Ø Open reduction external fixation Ø Closed reduction external fixation Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 32

Orthopedic Surgery Traction. A, Emergency traction using soft straps and rods. B, Skeletal traction of the femur following surgery to insert traction pins. (A from Wolinsky PR, Johnson KD: Femoral shaft fractures. In Browner BD, Jupiter TB: Levine AM, Trafteon PG [eds]: Skeletal trauma, ed 2, Philadelphia, 1998, WB Saunders; B from Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, Saunders. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 33

Orthopedic Surgery Ø Internal fixation devices • Implants are used to stabilize the fracture during bone healing Surgical steel Titanium Steel alloy Bioabsorbable implants Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 34

Orthopedic Surgery Ø Immobilization methods • Casts Proper placement of cast brings patient safety issues – Patient’s limb should be elevated – Webril should be placed so no wrinkles are in cotton to cause pressure sores – As plaster is placed, assistant must not make marks in plaster as it dries—these may cause pressure sores – Reflective materials will reflect heat given off by casting material and may burn patient’s limb – Tip of limb should be cleaned of all prepping solution so patient may be monitored for signs of circulatory disruption: increasing pain, pain that progresses into numbness, cyanotic skin, cold skin, poor capillary refill Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 35

Orthopedic Surgery Power equipment Ø Orthopedic drill and accessories. A, Electric drill and drill heads. B, Pneumatic low speed drill. C, Jacob's chuck. D, Jacob's chuck keys. (A from Tighe SM: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby; B-D Courtesy of Zimmer, Inc. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 36

Orthopedic Surgery Drill attachments Burr Ø Chuck Ø Depth gauge Ø Drill bit Ø Drill guide Ø Reamer Ø Shaver Ø Tip Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 37

Orthopedic Surgery Orthopedic instrumentation (cont. ) Ø Reamers (From Tighe S: Instrumentation for the operating room, ed 6, St Louis, 2003, Mosby. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 38

Orthopedic Surgery Drill bit. (From Browner BD, Jupiter JB, Levine AM, et al: Skeletal trauma: Basic science, management and reconstruction, ed 3, Philadelphia, 2003, Saunders. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 39

Orthopedic Surgery Types of saws Reciprocating saw Ø Sagittal saw Ø Oscillating saw Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 40

Orthopedic Surgery Hand Instruments Clamps. (Courtesy of Sklar Instruments. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 41

Orthopedic Surgery Measuring devices. (From Phillips N: Berry and Kohn's operating room technique, ed 11, St. Louis, Mosby, 2007. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 42

Orthopedic Surgery Periosteal elevators top to bottom: Freer, Langenbeck, Key, and Cushing elevators. (Picture courtesy of the College of Southern Idaho, Twin Falls, Idaho. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 43

Orthopedic Surgery Rongeurs A, Stille-Liston rongeur. C, Stille-Horsley rongeur. (Courtesy of Sklar Instruments. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 44

Orthopedic Surgery Osteotomes and Gouges D, Lambotte osteotome (often called "lambotte"). E, Smith Peterson gouge. (Courtesy of Sklar Instruments. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 45

Orthopedic Surgery Implants Pins and bolts Ø Nails and rods Ø Staples Ø Plates and screws Ø Screws Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 46

Orthopedic Surgery Implants (cont. ) Ø Sequential steps to orthopedic screw placement: 1. Drill a hole 2. Measure with a depth gauge 3. Tap 4. Place the screw Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 47

Orthopedic Surgery Implants, continued Ø Orthopedic implants • Documentation should include The patient’s permanent record The operative report The implant registry The manufacturer Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 48

Orthopedic Surgery Implant log Facility name and address Ø Manufacturer's identification information Ø Serial number, lot number, other information Ø Patient identification Ø Surgeon identification Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 49

Orthopedic Surgery Implant sterilization Prepackaged items come sterilized Ø Plates, screws, pins and rods come in trays Ø Joint and other specialty implants are sterilized and packaged by a manufacturer Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 50

Orthopedic Surgery Implant sterilization Ø Implants must not be flash-sterilized except in extreme emergencies, and then they should be accompanied by a biological indicator Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 51

Orthopedic Surgery Screws Head Ø Shaft Ø Threads Ø Tip Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 52

Orthopedic Surgery Types of screws Cancellous Ø Cortical Ø Lag Ø Herbert Ø Cannulated Ø Self-tapping Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 53

Orthopedic Surgery Plates Locking plate Ø Static or neutralization plate Ø Reconstruction plate Ø Dynamic compression plate (DCP) Ø Tension band plate Ø Buttressing Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 54

Orthopedic Surgery Intertrochanteric nail and plate Intramedullary nail or rod Wires and cables Kirschner (K-wire) and Steinman pins Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 55

Orthopedic Surgery Joint replacement implants Metals Cobalt-chromium-molybdenum Ø Titanium-aluminum-vanadium Ø Pure titanium Ø Tantalum Ø Polyethyelen Ceramic Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 56

Orthopedic Surgery Surface texture Rough ended Ø Beaded Ø Altered surfaces Ø Design Modular Ø Nonmodular Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 57

Orthopedic Surgery Graft Autograft • A segment of one’s own bone Ø Allograft • Cadaver bone Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 58

Orthopedic Surgery Bone graft substitutes Ø Ceramic • Composites of calcium phosphate, calcium sulfate, bioactive glass Ø Polymer • Cross-linked collagen or hydroxyapatite Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 59

Orthopedic Surgery Graft supplied in the following forms Injectable paste Ø Block form Ø Granules Ø Putty Ø Chips Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 60

Orthopedic Surgery Bone cement Polymethyl methacrylate (PMMA) Ø Used to secure and cement orthopedic implants • Total knee • Total hip • Total shoulder Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 61

Orthopedic Surgery Bone cement risk Occupational • Vapors released Ø Patient • Toxicity and vascular events Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 62

Orthopedic Surgery Bone cement safety Ø Two components that are combined and mixed in a closed container specially designed for use with PMMA Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 63

Orthopedic Surgery Casting Ø Ø Ø Types of casts: Short arm cast. Long arm cast. Plaster body jacket cast. One and one-half hip spica cast. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 64

Orthopedic Surgery Traction A. Emergency traction using soft straps and rods. B. Skeletal traction of the femur after surgery to insert traction pins. A from Wolinsky PR, Johnson KD: Femoral shaft procedures. In Browner BD, Jupiter TB, Levine AM, Trafteon PG, editors: Skeletal trauma, ed 2, Philadelphia, 1998, WB Saunders; B from Townsend CM: Sabiston textbook of surgery, ed 17, Philadelphia, 2001, WB Saunders Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 65

Orthopedic Surgery Types of traction Skin traction • Bucks traction Ø Skeletal traction • Modular rod and pin fixation Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 66

Orthopedic Surgery Arthroscopic surgery Review Chapter 20 on minimally invasive surgery Ø Instruments • Similar to those used on open procedures Ø Joint distension • Completed with continuous irrigation of saline or Ø lactated Ringer’s solution Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 67

Orthopedic Surgery Bankart Repair Ø The glenoid rim is reattached to the joint capsule with a biosynthetic or other anchoring device or with heavy sutures. Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 68

Orthopedic Surgery Ø Open rotator cuff repair • Goal is to repair disruption in rotator cuff Reduces pain and shoulder dysfunction • Shoulder is designed with almost limitless range of motion Price of such mobility is instability Rotator cuff and deltoid each provide about 50% of power needed for overhead lifting and 90% of power needed for external rotation Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 69

Orthopedic Surgery Proximal Plating of the Humerus A. Several 2 -mm Kirschner wires (K-wires) are inserted through the humerus to hold the fragments in place. B. The plate is positioned with one or two K-wires inserted through the screw holes. C. With the K-wires still in place, a drill guide is positioned to align drill holes for screws (Courtesy Zimmer, Warsaw, Ind. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 70

Orthopedic Surgery Proximal Plating of the Humerus (cont. ) D. Drill holes are made with a 3 -mm drill bit. The length of the hole is measured with a calibrated depth gauge. E. Bicortical screws are inserted into the proximal and distal ends of the plate. F. Completed repair. (Courtesy Zimmer, Warsaw, Ind. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 71

Orthopedic Surgery Arthroscopic procedures Ø Shoulder arthroscopy Posterior view for procedure of the glenohumeral joint and subacromial space. (From Miller MD, Chhabra AB, Hurwitz SR, Mihalko WM: Orthopaedic surgical approaches, Philadelphia, 2008, WB Saunders. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 72

Orthopedic Surgery Elbow Arthroplasty A. Areas of worn cartilage. B. Implant design. (Courtesy Zimmer, Warsaw, Ind. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 73

Orthopedic Surgery Anatomy of the hand. From Snell RS, Smith MS: Clinical anatomy for emergency medicine, St Louis, 1993, Mosby Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 74

Orthopedic Surgery Hand procedures Ø Specialized combination of • Orthopedics • Vascular • Neurosurgery • Plastics and reconstruction Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 75

Orthopedic Surgery Hand surgery anesthetics General Ø Regional Ø Local anesthesia Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 76

Orthopedic Surgery Open reduction and internal fixation of the wrist Ø Application of screws, plates, and pins for internal fixation of the wrist bones Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 77

Orthopedic Surgery Carpal tunnel release (CTR) Freeing of an entrapped median volar nerve to restore function to the wrist Ø Can be completed • Open • Endoscopically Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 78

Orthopedic Surgery Metacarpophalangeal joint (MPJ) arthroplasty A. A V-shaped incision is made. B. The flexor tendon is reattached. C. The collateral ligaments are released. D. The articular surface is exposed. E. The medullary canal is exposed. F. Trial implants and the permanent implant are inserted. G. The ligaments are reconstructed. (From Canale S, Beaty J: Campbell’s operative orthopaedics, ed 11, St Louis, 2007, Mosby) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 79

Orthopedic Surgery Dupuytren’s contracture release Common condition in which the fascia of the palm or fingers contracts Ø Constricted palmar fascia is incised and released to restore mobility to the hand fingers. Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 80

Orthopedic Surgery Repair of intertrochanteric fracture Ø A combination of femoral plate and compression lag screw used to stabilize a fracture of the femoral neck or proximal femur Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 81

Orthopedic Surgery Dynamic compression sliding hip screw. Functional loading of a sliding hip screw causes dynamic compression at the fracture site. With functional loading, the screw slides through the barrel of the side plate, allowing the fracture to impact or compress. Note the placement of the cannulated screw in the inferior third of the femoral neck. (From Browner BD, Jupiter JB, Levine AM, et al: Skeletal trauma: Basic science, management, and reconstruction, ed 3, Philadelphia, 2003, Saunders. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 82

Orthopedic Surgery Intramedullary femoral nailing Repair of a femoral shaft fracture using intramedullary femoral nails Ø A rigid rod seated in the medullary canal held in position by locking screws Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 83

Orthopedic Surgery Hip arthroplasty Ø Remove diseased components of the hip and replace them with prosthetic devices that restore function for the patient Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 84

Orthopedic Surgery Reasons for hip arthroplasty Osteoarthritis Ø Osteonecrosis Ø Acetabular fracture Ø Avascular necrosis Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 85

Orthopedic Surgery Components of a hip arthroplasty Femoral • Stem • Neck • head Ø Acetabular • Shell • liner Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 86

Orthopedic Surgery Fracture of the pelvis Completed for stabilization of the pelvis Ø Completed as an open procedure for reduction and repair Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 87

Orthopedic Surgery Knee arthroscopy Completed to diagnose knee pain and joint discomfort Ø Completed to repair knee and restore normal function Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 88

Orthopedic Surgery Knee arthroscopy Menisectomy Ø Anterior cruciate ligament (ACL) repair Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 89

Orthopedic Surgery Arthroscopic procedures Ø Arthroscopic anterior cruciate ligament (ACL) repair A. Removal of the graft from the tibial tuberosity B. Sutures may be placed at each end of the graft. C. The pilot holes are positioned to accommodate the graft D. The graft is secured with biosynthentic screws (From Canale S, Beaty J: Campbell’s operative orthopedics, ed 11, St Louis, 2007, Mosby) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 90

Orthopedic Surgery Knee arthroplasty Ø Removal of diseased components of the knee replaced with prosthesis to restore function of the knee Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 91

Orthopedic Surgery Knee arthroplasty components Femoral component Ø Tibial base plate Ø Polyethylene tibial insert Ø Patella component Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 92

Orthopedic Surgery Intramedullary nailing (tibia) Ø Placement of a solid rod into the medullary space of the tibia for repair of a comminuted fracture Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 93

Orthopedic Surgery Achilles tendon repair Tendon may be torn or ruptured during active sports such as tennis and basketball. Ø A low level injury could occur while cycling Ø Goal is to return strength and flexibility to the foot Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 94

Orthopedic Surgery Ø Percutaneous repair of the Achilles tendon • Incision smaller • Scar formation smaller • Tendon sheath holds clot that is formed, facilitating healing • No general anesthetic given • Accelerated rehabilitation possible, with full return to sports Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 95

Orthopedic Surgery Triple arthrodesis Surgical goal is to reduce pain of unstable ankle resulting from rheumatoid arthritis Ø Uses fusion to prevent full range of motion by ankle • After procedure, movement of foot and ankle Ø are limited to plantar flexion and dorsal flexion Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 96

Orthopedic Surgery Ankle fracture Open reduction and internal fixation is performed to stabilize fractures of the distal tibia, the talus, and the calcaneus Ø Completed using • Cannulated screws • Pins • Wire • Plates Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 97

Orthopedic Surgery Bunionectomy The goal is to alleviate pain and increase patient mobility Ø An enlarged metatarsal head is reduced or removed Ø Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 98

Orthopedic Surgery Hammertoe Correction Hammertoe repair. (From Herring JA: Tachdjian's pediatric orthopaedics from the Texas Scottish Rite Hospital for Children, ed 3, Philadelphia, 2002, Saunders. ) Elsevier items and derived items © 2010, 2007 by Saunders, an imprint of Elsevier Inc. 99