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Pelvic venography should be performed if there is any clinical suspicion of venous obstruction (ie, distal edema). Patients with tight skin closures are best served by leaving the skin open to avoid pressure-induced ischemia, and performing a primary or secondary split-thickness skin graft. A posterior needle biopsy is recommended for tumors arising within the body of the scapula; the anterior approach should be avoided. Dorsal scapholunate ligament reconstruction using a periosteal flap of iliac crest. Following isolated axillary tumor resection, the distal (humeral) transected edge of the latissimus dorsi muscle is rotated into the defect and sutured to the superficial surface of the subscapularis muscle to fill the dead space. Therefore, great care must be taken not to enter the tumor or the pericapsular structures of the prostate. All shoulder prosthetic systems now offer various humeral head sizes, and have eccentric offsets to match anatomy and fine tune stability. Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. Clinically this is similar to anterior interosseous nerve syndrome and must be distinguished clinically and often by electromyography. If not, the patient may require intravenous antibiotics and early pin removal, but this is extremely rare. Three weeks after tenotomy, after the final cast is removed, complete correction is obtained. Preoperative radiation is not used due to the risk of wound dehiscence or necrosis. The repair of the plantar soft tissue to the dorsal soft tissue is tenuous as there is no stout tissue dorsally to anchor the plantar flap. Attempting to abduct the complex clubfoot beyond 40 degrees results in no further hindfoot correction and only overabducts the forefoot, making immobilization of the foot in the cast more difficult. Biopsy the mere presence of a bone lesion with a presumed diagnosis of metastasis does not mandate a biopsy. Fluoroscopic evaluation can be useful, because it gives a complete circumferential view of the wrist and, with traction applied, can help evaluate injuries of the carpus. Failure to lengthen the checkrein ligaments may lead to an unacceptable contracture. The deltoid, subscapularis muscle, and remaining rotator cuff muscles are compressed into a pseudocapsular layer. The clinician should evaluate for other deformities, such as equinus, cavus, varus, adductus, and tibial torsion. It is important to clean the prosthetic stem of all cement after it has been inserted through the allograft. If the tumor is extremely large, only a subcutaneous flap is used, with the deep fascia remaining on the tumor side. Overtensioning of the soft tissues by repairing them first may prevent accurate reduction of the carpus. Use of a distraction plate for distal radial fractures with metaphyseal and diaphyseal comminution: surgical technique. The hazards of biopsy in patients with malignant primary bone and soft tissue tumors. The patient may have difficulty with weight-bearing activities, including walking and standing. Locating this tendon identifies the plane between the pectineus muscle and the obturator externus; a difference in the direction of the muscle fibers of these two muscles is also apparent. The profunda femoris artery branches to the medial aspect of the femoral artery 4 cm below the inguinal ligament. As long as no disease involves the area of the greater trochanter, this should be osteotomized and used in reconnecting the abductor mechanism.

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If stable, apply a removable wrist brace and instruct the patient to initiate gentle range-of-motion exercises of the fingers, wrist, and forearm twice or more daily as tolerated. Moving the scope superiorly yields oblique views of the proximal surface capitate and hamate as well as the capitohamate interosseous ligament. Consider volar buttress pin fixation for an extremely distal or dorsally rotated volar rim fragment. Chapter 5 Surgical Management of Metastatic Bone Disease: General Considerations Jacob Bickels and Martin M. This pseudocapsule consists of compressed tumor cells and a fibrovascular zone of reactive tissue with a variable inflammatory component that interacts with the surrounding normal tissues. Current concepts in volar fixed-angle fixation of unstable distal radius fractures. Therefore, an osteotomy is performed through the wing of the ilium starting at the sciatic notch. The examiner should palpate the anatomic snuffbox, which lies on the dorsum of the wrist between the extensor pollicis longus and extensor pollicis brevis tendons. Direct pour of liquid nitrogen into the tumor cavity, which is irrigated continuously with warm saline throughout the freezing and thawing processes (5 minutes altogether). A thin amount of plaster is applied and the foot is held in position while the plaster sets. Follow the distal stump of the notch-lengthened posterior tibial tendon to its insertion on the navicular. The proximal femoral modular prosthesis comprises a proximal bipolar part, a body, and a distal rounded tip. Release of the gastrocnemius heads, which are then reflected distally for maximal exposure. Local anesthesia with sedation is preferred, but regional or general anesthesia is acceptable. In the absence of concomitant pathology, provocative maneuvers such as Watson and shuck tests are negative. Resection of Posterior Axillary Tumors Resection of Anterior Axillary and Chest Wall Tumors Tumors involving the pectoralis and serratus anterior can be resected safely following identification and mobilization of the critical neurovascular structures; these muscles may be elevated directly off the underlying chest wall. With this procedure, the T-saw placed around the lamina is wrapped around the pedicle. Non-union of the scaphoid: treatment with cannulated screws compared with treatment with Herbert screws. The injury can result from axial, bending, and torsional loads, or combinations thereof. Tumor response is measured by tumor necrosis rate on microscopic pathology and is a significant prognostic factor. A number of classification systems have been introduced, the most commonly used being those of DiMeglio and Pirani. The deltoid, although it is not typically considered one of the compartmental borders, since it attaches to a narrow region of the scapular spine and acromion, may be involved secondarily by a large soft tissue extension. Any surgery in this region requires detailed knowledge of and familiarity with these structures. It should bow, showing that tension has been applied across the construct and thus traction across the joint. These lesions commonly present as a painless, slow-growing mass, but in 20% of patients they present as a painful, rapidly growing mass. Venography: the major veins may be occluded due to pressure of the soft tissue mass or invasion of the vascular sheath, and therefore by inference the major artery or nerves may be involved by tumor. The clinical and functional results following saddle reconstruction of the pelvis with this system have been promising. A central drill hole is made carefully to accept the sliding component and distal femoral stem.

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Blunt dissection is carried down with a hemostat, and the arthroscope, with a blunt trocar, is introduced into the dorsal 3/4 portal. Long-term results of endoprosthetic reconstruction after segmental bone resection for bone tumors: analysis of 242 patients over 22 years of institutional experience. With this procedure, a complete anterior and posterior decompression of the spinal cord (circumspinal decompression) and total en bloc resection of the vertebral tumor are achieved. The long-stemmed Neer prosthesis was developed to re-establish humerus length and to avoid the problem of proximal migration. Three types of osteotomies may be used for periacetabular resection: (1) supra-acetabular osteotomy; (2) superior pubic ramus osteotomy; and (3) ischial osteotomy. Newer prognostic studies of soft tissue sarcomas do not support the assumption that space tumors have a worse prognosis due to their location but rather due to their size. These neoplasms represent less than 1% of all adult and 15% of pediatric malignancies. Resection of high-grade sarcomas may require sacrifice of one or more major branches of the brachial plexus to achieve an adequate oncologic margin. The drill diameter is roughly the diameter of the extensor hallucis longus tendon. A whipstitch is placed into the cut end of the extensor hallucis longus tendon (inset) and the tendon is passed through a transverse drill hole and sutured to itself. The anterior tibial artery and often the peroneal vessels are ligated if there is a large posterior component to the tumor. The bladder is retracted with a malleable retractor, and an additional small malleable retractor is placed beneath the symphysis pubis notch to protect the urethra. In fact, the middle phalanx is narrowest at this point, so the wire is more easily placed distally. Complete decortication is verified from both the radiocarpal and midcarpal joints. The popliteal vessels enter the popliteal space from the medial aspect through the adductor hiatus as the vessels exit the sartorial canal. The main mechanisms of knee joint contamination are inappropriate biopsy, extension of tumor along the intra-articular cruciate ligaments, and pathologic fracture. In the small finger, the scars (dotted lines) were midlateral and the exposure was planned in that fashion. The first is found where the anterior tibial artery arises from the popliteal artery, which then continues as the tibioperoneal trunk. In addition, patients with extremely large sarcomas involving multiple compartments of the thigh may require an immediate amputation to avoid tumor fungation, hemorrhage, and secondary infection. By 3 months, the tendon graft and junction sites should be strong enough to allow for unrestricted active motion. High-grade sarcomas that arise from the proximal humerus or scapula are likely to contaminate or cross the glenohumeral joint, either grossly or microscopically. It is not necessary to reattach the pectoralis to its insertion; rotation of this muscle is valuable for reconstruction of defects around the shoulder. Failure to restore a concave joint surface creates a flat surface (D) that encourages dorsal subluxation of the middle phalanx (E). An obtuse scapholunate angle (60 degrees) is appreciated on a lateral view of the wrist. Radial-based volar and dorsal ligaments arise from the distal radius to support the wrist. The iliotibial band is transected from its origin from the iliac crest and reflected posteriorly along with the gluteus maximus. Likewise, proximal transfer (ie, tensioning) of the brachioradialis and forearm flexor origins (ie, flexorplasty) is beneficial for restoring elbow flexion power. Tumor removal, cemented nailing, and postoperative radiation most likely would have resulted in local tumor control and durable reconstruction. These vessels course along the deep margin of the myocutaneous flap, and in the subsequent dissection they are traced superiorly to the inguinal ligament.

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These tumors arise within a structure-thigh: anterior, adductor, posterior; leg: anterior, peroneal, posterior superficial, posterior deep. Using electrocautery, the glutei are detached and reflected from the outer iliac table. The degree to which the initial surgical volume should be decreased in these circumstances is controversial, although the rate of local recurrence following a wide excision and postoperative radiation therapy is 5% to 10%. Phantom pain or causalgia syndromes may occur and are difficult to predict, although patients with significant preoperative pain complain of postoperative pain more often. The neurovascular structures are approached from the back, unless the tumor has an anterior extraosseous component. A straight horizontal incision is made along the medial aspect of the hindfoot centered over the sustentaculum tali. The graft (red vessel loop) exits the radial bone hole (short arrow) into the dorsal wound and then enters the ulnar bone hole through the fovea (long arrow). The musculocutaneous nerve is the first nerve that leaves between the teres major and minor to innervate the deltoid muscle posteriorly. Patients occasionally report a snap or twinge of discomfort as the tendon ruptures. The flap is tacked down to the underlying hip rotator muscles and abductor muscles to avoid a postoperative seroma. F, femoral nerve; S, sciatic nerve; arrow indicates Renografin (contrast) in sciatic sheath. Lateral plain radiograph of the lumbar spine, showing metastatic high-grade osteosarcoma to the body of L3 vertebra (arrow). Slight varus or valgus does not seem to interfere with function or lead to loosening. The patients also understands what has happened and is often clearer about the postoperative regimen. The extremity is kept in a splint for a total of 6 weeks to allow for sufficient muscle healing and scarring. Chapter 25 Ligament Stabilization of the Unstable Thumb Carpometacarpal Joint Richard Y. Dynamic forefoot supination deformity results from residual medial displacement of the navicular on the head of the talus, which results in muscle imbalance. Percutaneous pins can support the subchondral area of the distal radius and maintain the articular reduction in highly comminuted fractures, which is useful in combined fixation methods. An appropriate drill hole is then made in the cuboid, drilling dorsal to plantar in line with the fourth metatarsal axis and through the plantar aspect of the bone. Aim 1 to 2 mm proximal rather than distal to remain extracapsular (the capsule of the joint reflects proximally). A small longitudinal portal incision is made about 2 cm proximal to the medial epicondyle and just anterior to the medial intermuscular septum. Postoperative radiograph demonstrating proximal femoral replacement following tumor resection. This is especially useful in obese patients in whom the sacroiliac joint cannot easily be palpated. Uterine restriction: A reduced amount of amniotic fluid causes limited fetal foot movement and, incidentally, clubfoot. At week 18, resistance strengthening can be increased to a 5-pound weight limit if the patient is now able to handle 2 pounds.

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When the advancing tip of the Kirschner wire hits the far cortex, place a drill sleeve over the Kirschner wire to use as a drill stop to limit penetration of the far cortex to 1 to 2 mm. The K-wires allow for fine adjustment in plate position before committing to insertion of a screw. Then the entire vastus lateralis can be flipped up over the femur, exposing the entire length of the bone. In older children, a small periosteal elevator is used to elevate the periosteal flaps off the lateral cuneiform. Patients with a greater extension lag after 6 weeks may benefit from 2 or 3 more weeks of full-time splinting. Venography also can indirectly assess tumor invasion into major nerves that lie in close proximity. The suture can be removed in 2 to 3 weeks, but the splinting should continue for a total of 6 weeks full time and another 6 weeks at night. A side-cutting burr is used to remove the cartilage within the scapholunate joint. With the foot positioned for the Coleman block test, a lateral radiograph of the foot can document the degree of hindfoot correction. The tendons are first exposed in an unaffected area, proximal and distal to the scar. Intraoperative photographs showing a locally recurrent osteosarcoma at the proximal arm and axilla in a 34-year-old patient E. If an open wound is present or the joint cannot be manipulated into an acceptable reduction, such as may occur with soft tissue entrapment, open reduction becomes necessary. A component of subtalar joint eversion is dorsiflexion of the calcaneus in relation to the talus. If only a very small (and possibly an avascular) proximal pole remains, the carpus is likely to collapse, resulting in failure of the procedure. In a Chopart amputation, the talus and calcaneus should be cut and contoured to fit a prosthesis. Once the superficial femoral artery is identified, it is clamped, divided, and ligated as distally as oncologically possible. Thermocouples are used to monitor the freeze within the cavity, cavity wall, adjacent soft tissues, and an area 1 to 2 mm from the periphery of the cavity. The A1 pulley area is prepped with an antiseptic solution such as alcohol or betadine. The incision starts over the junction of the inner and middle thirds of the clavicle. Clinical results of intraarticular fractures of the base of the fifth metacarpal treated by closed reduction and cast immobilization. Intraoperative photograph demonstrating the creation of the deep notch (large arrows). Venous occlusion may be seen in neglected, massive tumors and is a harbinger of loss of limb and possibly even of life due to gangrene. Positioning Arthroscopic-assisted fixation of distal radius fractures may be performed with the arm suspended vertically in a traction tower, horizontally in a traction tower, or with finger traps applied attached to weights hanging over the edge of the hand table. The musculocutaneous nerve and the biceps attachment to the coracoid are identified along with the nerves of the brachial plexus and vessels. The pectoralis major is repaired to its humeral insertion or, in cases requiring extraarticular proximal humerus reconstruction, transferred to cover the prosthesis with soft tissues. With median nerve entrapment and compression from the proliferative tenosynovitis at the level of the radiocarpal joint, disability becomes more progressive and nonsurgical treatment more difficult. Technetium bone scan has been shown to be up to 100% sensitive in identifying occult fractures but lacks specificity. Second, it is a gravity-dependent procedure, ie, the poured liquid cannot reach corners of the tumor cavity that are positioned above the fluid level.

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Type I injury If the force of injury is mild, partial disruption of the collateral ligaments and the volar plate at its distal insertion on the middle phalanx are the only consequences. Close weekly follow-up for the first 3 weeks is necessary to monitor for any loss of reduction. The flexor sheath is incised as a rectangular flap between the A2 and A4 pulleys and protected for later repair. In mild equinus, the normal heel-to-toe gait of the plantargrade foot will be replaced with early lift-off during stance. Range of motion: equinus Ankle motion (dorsiflexion and plantarflexion) is assessed in both knee extension and flexion. This can be facilitated by the use of a Beaver blade, a dental pick, and a fine synovial rongeur. Several collateral vessels come off the femoral vessels at this point, coursing toward the femur and tumor. The deltopectoral interval should not be used, because biopsy here would contaminate the deltopectoral fascia, the subscapu-laris, and the pectoralis major muscles, and would jeopardize the possibility of performing an adequate resection through uninvolved tissue planes. Tibial allograft is recommended due to its suitable thickness and mechanical characteristics, which provide excellent screw purchase. One important disadvantage is the creation of a relatively large defect and stress riser within the distal radius. Assessment for tumor extension to this area is particularly important in planning the flaps that will be used. The advantages of this technique include its simplicity and the early mobility it affords an injured joint. Careful analysis of the popliteal trifurcation is necessary before surgery and may indicate tumor involvement and thus the need for an amputation. The open sliding Achilles lengthening technique, first described by White,9 is performed with partial transections at the (1) proximal and medial and (2) distal and anterior portions of the tendon. Monitoring the rare occurrence of local anesthetic toxicity mandates full monitoring in the operating room and in areas where blocks may be done before surgery. Routine placement of a nasogastric tube and avoidance of oral feeding are required to prevent nausea, vomiting, aspiration, abdominal distention, and wound complications. Preoperative Planning Consider withholding rheumatoid medications (eg, methotrexate, Etanercept, Imuran) 1 week before and 1 week after surgery. Lymphedema may result in significant disability and chronic pain; early aggressive treatment may lessen the severity or duration of swelling. Intramedullary fixation is stronger, provides more protection against late allograft fracture, and makes restoration of sagittal and coronal plate alignment easier. The limb should be draped in such a way as to be left free and mobile during the procedure. The superficial fascia is closed with absorbable suture, and the skin is closed with clips. Insert a 2-mm full-radius shaver in the ulnar portal and evacuate the hematoma and any minute bone fragments that may prevent visualization. Aggressive benign bone tumors (stage 3) may cause destruction of surrounding bone and usually break through the cortex into the surrounding soft tissues. Isolated ulnar fractures most commonly occur when the forearm is struck by an object, explaining the eponym "nightstick fracture. The digital neurovascular structures are right next to the A1 pulley and must be protected. A dynamic extension splint may be used at 6 weeks if the achieved extension is not as expected based on intraoperative range of motion. Failure to recognize an associated carpal instability pattern can lead to progressive carpal collapse and degeneration. We believe pain should be treated perioperatively by inserting an epineural catheter into the transected tip of the sciatic nerve. The foot-to-tibia angle is measured to assess the amount of equinus in the frontal plane and the amount of heel varus in the sagittal plane.

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Two of the polyethylene component failures occurred in the same patient; the first occurred 2. To ensure that the extensor tendons are not entrapped, use a hemostat to thread either end of the suture underneath the extensor compartment. It passes over the superficial iliacus muscle to enter the proximal thigh underneath the inguinal ligament, just lateral to the superficial femoral artery. Lumbar Plexus Sensory Nerves the iliohypogastric (L1), ilioinguinal (L1), genitofemoral (L1, 2) and lateral femoral cutaneous nerves, which arises from L2 and L3, travel downward laterally along the iliopsoas muscle, pass underneath the lateral aspect of the inguinal ligament, and pass just distal and medial to the anterior superior iliac crest to innervate the anterolateral thigh. That system is based on the biologic behavior of these tumors as suggested by their clinical manifestation and radiologic findings. Under fluoroscopic guidance, gently pronate the wrist until the scaphoid appears as an oblong cylinder, indicating that the proximal and distal poles are aligned. To prevent a large postoperative seroma, the large posterior fasciocutaneous flap must be tacked down to the remaining underlying muscle very carefully. The surgeon needs to be aware of the potential risk of extensor lag, and we recommend attention to the defect by suture repair. Theoretically, the asymmetric wear of the articular cartilage resulting from chronic laxity causes degeneration of the articular cartilage. The surgeon must contact a tissue bank, preferably one accredited by the American Association of Tissue Banks, to ensure that a frozen humerus is available before the procedure. The management of acetabular insufficiency secondary to metastatic malignant disease. A prolonged duration of immobilization is often required for waist fractures, and this can be accompanied by muscle atrophy, stiffness, reduced grip strength, and residual pain. In another study by Chapman,7 98% of the fractures united, and 92% of the patients achieved an excellent or satisfactory functional result. For the first week, the orthosis and socks should be removed with every diaper change to inspect the feet for evidence of developing pressure sores. There has been renewed interest in dorsal plating of the distal radius as it has been shown to have a low rate of tendonrelated complications with the use of low-profile, anatomic implants. Preserving hip function is the main advantage of stump prosthesis over hip disarticulation. During the first stage of the reconstruction process, a silicone rod is placed within the flexor tendon sheath. A radially based capsular flap is created by incising the dorsal capsule along the fibers of both the dorsal radiotriquetral ligament and the dorsal intercarpal ligament. The entire triceps surae (gastrocnemius and soleus) is contracted if the ankle does not dorsiflex at least 10 degrees above neutral with the knee flexed or extended. An isolated tear of the dorsal joint capsule very rarely causes volar subluxation without an associated collateral ligament injury. An ulnar nerve transposition may be performed, although this is not done routinely. Muscle balancing is better left for a later time, after rehabilitation from extensive surgical release. With these two muscles released, the axillary space and infraclavicular component of the brachial plexus (ie, the axillary vein and artery through its entire length) can be explored completely. It is important to dissect the musculocutaneous nerve from around the coracoid as it enters the short head of the biceps to avoid nerve injury. It is reasonable to consider nonoperative treatment of an isolated ulna fracture with less than 10 degrees angulation,21 but nonoperative treatment of both-bone forearm fractures has a poor outcome. These three muscle groups must be attached properly: correct restoration of muscle origin attachment allows function of the glutei and iliacus muscles; and restoration of abdominal wall continuity prevents herniation of the pelvic viscera to the flank. An acute scapholunate injury may or may not coincide with an injury to the surrounding ligaments (ie, dorsal extrinsics). Most tumors of the quadriceps muscle will displace but not invade the superficial femoral or common femoral arteries. With ultrasound, it is possible to visualize, in real time, images of the nerve, the needle approaching the nerve, and Table 7 Additive Additives to Local Anesthetics Dosage 2. Most patients have depressed immune systems from chronic disease, chemotherapy, and malnutrition. These studies are useful for diagnosis, evaluating local and distant extent of disease, and, for select sarcomas, gauging the response to preoperative chemotherapy. Open reduction and repair Untreated complete tears of the scapholunate interosseous ligament, which are highly associated with radial styloid fractures, may progress to a wrist with scapholunate advanced collapse.