Advanced Orthopaedics: Principles and Techniques

235 Pages·2013·10.015 MB·English

by  MD Ruben P. Arafiles, NA, NA, NA, NA, NA, NA, NA, NA, NA, NA, NA, NA, NA

ADVANCED ORTHOPAEDICS:
Principles and Techniques

ADVANCED ORTHOPAEDICS:
Principles and Techniques
Ruben P. Arafiles, M.D.
Clinical Fellow (June, 2004 to July, 2005), Rubin Institute for Advanced
Orthopaedics, Baltimore
International Affiliate Member, American Academy of Orthopaedic Surgeons
Orthopaedic Surgeon, Guam Memorial Hospital Authority,
Tamuning, Guam, USA
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Publisher: Ruben P. Arafiles
PO Box 7540
Tamuning, Guam 96931
Advanced Orthopaedics: Principles and Techniques ISBN-13 : 978-0-615-64409-7
Copyright: 2013
All rights reserved. No part of this publication may be reproduced or transmitted in any form or
by any means, electronic or mechanical, including photocopying, recording, or any information
storage or retrieval system, without permission in writing from the publisher. Permission may be
sought directly from Dr. Arafiles at ([email protected]).
Notice
Knowledge and best practice in this field are constantly changing. As new research and
experience broaden our knowledge, changes in practice, treatment and drug therapy may become
necessary or appropriate. Readers are advised to check the most current information provided (i)
on procedures featured or (ii) by the manufacturer of each product to be administered, to verify
the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of the practitioner, relying on their own experience and
knowledge of the patient, to make diagnosis, to determine dosages and the best treatment for
each individual patient, and to take all appropriate safety precautions. To the fullest extent of the
law, neither the Publisher nor the Editors or Author assume any liability and/or damage to
persons or property arising out of or related to any use of the material contained in this book.
Library of Congress Cataloging-in-Publication
Advanced Orthopaedics: Principles and Technique Ruben P. Arafiles First ed.
Includes bibliographical references and index.
ISBN-13: 978-0-615-64409-7
1. Orthopaedics 2. Surgery 3. Limb-lengthening 4. Deformity 5. Ilizarov
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To my father, Catalino Perez Arafiles,
who believed I would make a fine doctor,
when I wanted to be something else.
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Preface
This book is all about principles and techniques. It is For several years before I went to Baltimore, I have been
written for the busy surgeon or health professional with doing Ilizarov surgeries using locally developed and
little time to go through the literature but who needs to manufactured stainless steel half-rings, clickers, and
get to the essentials to provide optimum care for his or her wire tensioners. I therefore found myself at home at the
patients. It is written too for orthopaedic residents who Rubin Institute, applying the same principles, albeit with
may not have the chance to get into a limb lengthening modern devices. This is the topic in Chapter 4, “Modern
fellowship. Ilizarov Techniques”.
I was fortunate to have been chosen as clinical fellow In this book, I included the most recent views and
in limb lengthening at the Rubin Institute of Advanced opinions available in the literature. The procedures are
Orthopaedics in Baltimore by Drs. Dror Paley and John illustrated with numerous intraoperative step-by-step
Herzenberg, both co-directors of the Institute at the time. pictures which to the interested reader can serve as a
Many of the surgeries included in this book were done by substitute for witnessing the surgery itself. Some subjects
these two renowned masters of limb lengthening. which to others may seem important have been left out;
for this I apologize.
At 58, I was the oldest clinical fellow then. The late hours
spent in preparing preoperative cases for presentations I am especially grateful to the consultant staff of the
and long hours of assisting in surgeries took a great toll Rubin Institute of Advanced Orthopaedics who shared
on me. I may have seemed to be just going through the their expertise and their patients: Dr. Dror Paley, Dr.
motions of fellowship training. In reality, my exposure John Herzenberg, Dr. Shawn Standard, Dr. Janet Conway,
to the group had a profound impact on me. I was most Dr. Bradlley Lamm and Anil Bhave, PT. My thanks too,
impressed by their focus and industry, by the joyful to the other clinical fellows, Dr. Nikolaos Bardakos,
dedication with which they practice their craft, and by Dr. Mathew Testani, and Dr. Ragurham Thonse; I enjoyed
the way they apply the principles that they have learned working and sharing patients with them. The research
through the years, from others and from their own fellows were very supportive in taking over the occasional
studies, thus coming up with truly innovative methods extra work, and the employees of the Institute were very
of treatment. This book is a modest effort to share this gracious in helping gather important details. All these
experience with others. people were essential in the coming together of this work.
The topics I chose include most of the types of patients I acknowledge the invaluable help of my wife, Naia B.
encountered at the Sinai Hospital in Baltimore, at the Arafiles, MD, in the preparation of the manuscript, and
Limb Lengthening Institute as well as the Center for my daughter Rebecca, for the cover design.
Joint Preservation. Many cases are my personal patients
at the Commonwealth Health Center in Saipan, Northern
Mariana Islands, where I tried to improvise as much as
Ruben P. Arafiles, M.D.
I could with the available resources. I added too a few
surgeries I did at the Asian Hospital and Medical Center
in Manila.
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Contents
Title Page/Author Details i 14
CHAPTER
ISBN Details/Date of Publication ii Joint Preservation Surgery of the Hip 138
15
CHAPTER
Dedication iii
Osteotomies Around the Knee 150
Preface iv
16
CHAPTER
1
CHAPTER Blount’s Disease 159
Basic Measurements 1 17
CHAPTER
CHAPTER 2 Patellar and Extensor mechanism Disorders 163
Deformity Correction Using CHAPTER 18
the Taylor Spatial Frame 8
Resistant Clubfoot and Ilizarov Correction
CHAPTER 3 of Foot Deformities 171
Quadricepsplasty 22 CHAPTER 19
4
CHAPTER Diabetic Foot Deformities 176
Modern Ilizarov Techniques 26 20
CHAPTER
5
CHAPTER Joint Replacement and
Arthrodiastasis for Legg-Calve-Perthes Deformity Correction 182
and Avascular Necrosis of the Hip 48 21
CHAPTER
6
CHAPTER
Spine Deformity Correction:
Hip, knee Reconstruction, and The Importance of Sagittal Alignment 188
Limb Lengthening in Congenital 22
CHAPTER
Femoral Deficiency 61
Acute Compartment Syndrome 195
7
CHAPTER 23
CHAPTER
Limb Lengthening and Reconstruction for
Nerve Decompression 203
Fibular Hemimelia 80
CHAPTER 8 APPENDIX 207
Reconstruction and Lengthening
for Radial Clubhand 91 INDEX 219
9
CHAPTER
Congenital Pseudarthrosis of the Tibia 96
10
CHAPTER
Tibial Hemimelia 104
11
CHAPTER
Nonunion 112
12
CHAPTER
Limb Lengthening for Achondroplasia 118
13
CHAPTER
Elbow Contracture and Instability 129
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CHAPTER 1
Basic Measurements
Leg Length Inequality
Deformity evaluation and correction require Erect leg view films are taken with the x-ray beam at
the following basic measurements: leg length knee level and at a tube-to-subject distance of 10 feet
discrepancy, mechanical axis deviation, joint (Fig 1.) Scannograms are not useful because these
orientation angles and thigh foot angle. The accurate do not allow measurement of angular or translational
determination of all these measurements, except the deformities of the shafts of long bones, foot height,
thigh foot angle, require radiographic views[l]. To and mechanical axis deviation [2,6]. In a study
measure leg lengths, place 1 cm thick wooden blocks comparing computed radiographic measurements
under the short leg in a standing patient, palpate the (taken supine) with erect leg views (standing or
iliac crests, and add or remove blocks until the patient weight-bearing), Sabharwal and colleagues found
feels that he or she is standing level. An erect leg AP that the measurements were similar only in patients
view can then be taken, and leg lengths measured with less than 2 cm of mechanical axis deviation, no
directly from the film. The conventional technique of valgus and varus malalignment, and no subluxation
measuring leg lengths, i.e., measuring the distance or joint narrowing [6]. Therefore, they did not
from the anterior superior iliac spine (ASIS) to the recommend computed radiography for routine use in
medial malleolus with the patient supine, is difficult patients with leg length discrepancy.
especially in the obese, or in patients with less
prominent ASIS.
Fig. 1 T his shows the method of taking an erect leg view in a patient with leg length inequality. There is a one-cm thick
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