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MILLER’S REVIEW OF ORTHOPAEDICS MILLER’S REVIEW OF ORTHOPAEDICS SEVENTH EDITION MARK D. MILLER, MD S. Ward Casscells Professor Head, Division of Sports Medicine Department of Orthopaedic Surgery University of Virginia Charlottesville, Virginia Team Physician James Madison University Founder and Director Miller Review Course Denver, Colorado STEPHEN R. THOMPSON, MD, MEd, FRCSC Cooperating Associate Professor of Sports Medicine The University of Maine Medical Director EMMC Sports Health Deputy Editor The Journal of Bone and Joint Surgery Eastern Maine Medical Center Bangor, Maine Cofounder and Codirector Miller Review Course Part II Denver, Colorado 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 MILLER’S REVIEW OF ORTHOPAEDICS, SEVENTH EDITION ISBN: 978-0-323-35517-9 Copyright © 2016 by Elsevier, Inc. 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 and retrieval system, without permission in writing from the Publisher. Details on how to seek permission, further information about the Publisher’s permissions policies, and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein). Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods, they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, 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 practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, 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 authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence, or otherwise or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Previous editions copyrighted 2012, 2004, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc. Library of Congress Cataloging-in-Publication Data Names: Miller, Mark D., editor. | Thompson, Stephen R., editor. Title: Miller’s review of orthopaedics / [edited by] Mark D. Miller, Stephen R. Thompson. Description: Seventh edition. | Philadelphia, PA : Elsevier, [2016] | Includes bibliographical references and index. Identifiers: LCCN 2015041690 | ISBN 9780323355179 (pbk. : alk. paper) Subjects: | MESH: Musculoskeletal Diseases–Outlines. | Orthopedic Procedures–Outlines. Classification: LCC RD731 | NLM WE 18.2 | DDC 616.7–dc23 LC record available at http://lccn.loc.gov/2015041690 Executive Content Strategist: Dolores Meloni Content Development Specialist: Laura Schmidt Publishing Services Manager: Catherine Jackson Senior Project Manager: Doug Turner Book Designer: Renee Duenow Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 In loving memory of my father, Dr. Monte B. Miller, former Surgeon General of the U.S. Air Force and a great educator— I never met a person who did not respect him— and my mother, Christine F. Miller, a kind woman whose strength was admirable Mark D. Miller For Harper Finn, who taught me that there is more to the world than what exists within these pages Stephen R. Thompson CONTRIBUTORS Ermias S. Abebe, MD David J. Hak, MD, MBA, FACS Resident Professor Department of Orthopaedic Surgery Department of Orthopaedic Surgery University of Pittsburgh Medical Center Denver Health/University of Colorado Pittsburgh, Pennsylvania Denver, Colorado James A. Browne, MD Joseph M. Hart, PhD, ATC Assistant Professor Associate Professor Department of Orthopaedic Surgery Kinesiology University of Virginia University of Virginia Charlottesville, Virginia Director, Clinical Research Department of Orthopaedic Surgery Lance M. Brunton, MD University of Virginia Clinical Assistant Professor Charlottesville, Virginia Department of Orthopaedic Surgery University of Pittsburgh Medical Center MaCalus Vinson Hogan, MD Pittsburgh, Pennsylvania Assistant Professor Attending Staff Department of Orthopaedic Surgery Excela Health Orthopaedics and Sports Medicine University of Pittsburgh Medical Center Latrobe, Pennsylvania Associate Residency Program Director Department of Orthopaedic Surgery M. Tyrrell Burrus, MD University of Pittsburgh Medical Center Resident Physician Pittsburgh, Pennsylvania Department of Orthopaedic Surgery University of Virginia Health System Ginger E. Holt, MD Charlottesville, Virginia Associate Professor Orthopaedic Surgery and Rehabilitation Bobby Chhabra, MD Orthopaedic Oncologist Professor and Chair Vanderbilt Medical Center Department of Orthopaedic Surgery Nashville, Tennessee University of Virginia Health System Charlottesville, Virginia Anish Kadakia, MD Staff Orthopedic Surgeon Marc McCord DeHart, MD Department of Orthopedic Surgery Clinical Assistant Professor Illinois Bone and Joint Institute Orthopaedic Surgery and Rehabilitation Glenview, Illinois University of Texas Medical Branch Clinical Educator Galveston, Texas Department of Orthopedic Surgery Clinical Assistant Professor University Of Chicago Department of Surgery Chicago, Illinois Texas A&M Health Science Center College of Medicine Cyril Mauffrey, MD Round Rock, Texas Associate Professor Department of Orthopaedic Surgery F. Winston Gwathmey, Jr., MD Denver Health/University of Colorado Assistant Professor Denver, Colorado Department of Orthopaedic Surgery University of Virginia Edward J. McPherson, MD Charlottesville, Virginia Director and Founder LA Orthopedic Institute Los Angeles, California vii viii Contributors Todd A. Milbrandt, MD, MS Jeffrey D. Seybold, MD Pediatric Orthopaedic Surgeon Orthopaedic Surgeon Orthopaedic Surgery Twin Cities Orthopedics Mayo Clinic Edina, Minnesota Rochester, Minnesota Francis H. Shen, MD Mark D. Miller, MD Warren G. Stamp Endowed Professor S. Ward Casscells Professor Division Head, Spine Division Head, Division of Sports Medicine Co-Director, Spine Center Department of Orthopaedic Surgery Department of Orthopaedic Surgery University of Virginia University of Virginia Health Systems Charlottesville, Virginia Charlottesville, Virginia Team Physician James Madison University Franklin D. Shuler, MD, PhD Founder and Director Professor of Orthopedic Traumatology Miller Review Course Orthopedics Denver, Colorado Marshall University Joan C. Edwards School of Medicine Vice Chairman of Research Zain N. Qazi, MD Orthopedics Surgery Resident Cabell Huntington Hospital University of Washington Medical Center Huntington, West Virginia Seattle, Washington Former Research Fellow Stephen R. Thompson, MD, MEd, FRCSC Department of Orthopaedic Surgery Cooperating Associate Professor of Sports Medicine Joan C. Edwards School of Medicine The University of Maine Marshall University Medical Director Huntington, West Virginia EMMC Sports Health Deputy Editor Jeremy Rush, MD The Journal of Bone and Joint Surgery Pediatric Orthopaedic Surgeon Eastern Maine Medical Center San Antonio Military Medical Center Bangor, Maine Fort Sam Houston Cofounder and Codirector San Antonio, Texas Miller Review Course Part II Assistant Professor Denver, Colorado Department of Surgery Herbert School of Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland Matthew R. Schmitz, MD Chief, Pediatric Orthopaedics and Young Adult Hip Preservation Department of Orthopaedics and Rehabilitation San Antonio Military Medical Center San Antonio, Texas Assistant Professor Department of Surgery Herbert School of Medicine Uniformed Services University of the Health Sciences Bethesda, Maryland PREFACE Congratulations! You have in your hands one of the most Lauerman. Please note the tribute to him in Dr. Shen’s popular books in the history of orthopaedic surgery. The chapter. odyssey from the first edition—which began as little more • Chapter 9, “Orthopaedic Pathology”: Dr. Holt made updat- than compiled notes with a working title of Basic Orthopaedic ing this important area of practice her personal mission, Notes Edited (BONE) and “scrapbook art” picked up from other and it is a masterpiece (just like her lectures at MRC). Saunders/Mosby (now Elsevier) textbooks—to the seventh • Chapter 10, “Rehabilitation”: Dr. Hogan, new to both MRC edition has been quite an adventure. What has made that and this book, did a great job with a very thorough adventure especially rewarding is the crew that we have revision. assembled along the way. The seventh edition of this book • Chapter 11, “Trauma”: Dr. Hak took on the challenge of personifies, in all ways, a team effort. We invited many new reorganizing and revising this important chapter, and it is but seasoned authors, mostly from our popular Miller Review much improved. Course (MRC), to participate in the creation in this edition. • Chapter 12, “Principles of Practice”: Dr. DeHart, one of the Most were assigned new coauthors and/or sections that they few remaining original MRC faculty members, has done had not worked on before. his usual excellent job in updating this difficult chapter. All chapters in the seventh edition have undergone major • Chapter 13, “Biostatistics and Research Design”: Dr. Hart revisions: has a knack for making statistics and research understand- • Chapter 1, “Basic Science”: We assembled the team that able, if not fun (OK, we won’t go that far). covers this exhaustive topic for MRC and asked them to A lot of thought went into the reorganization of this completely revise the text. popular text. We tried to put things where they belong, based • Chapter 2, “Anatomy”: We asked Dr. Gwathmey, who has on what subspecialty would most likely be used to treat a taken over the orthopaedic anatomy course at the Univer- given condition. We began by cleaning up the sports medicine sity of Virginia, to reorganize and update this material. chapter by removing much of the overlap with other subspe- • Chapter 3, “Pediatric Orthopaedics”: Dr. Schmitz, a young cialties. Sports foot and ankle was transferred to the foot and and energetic pediatric orthopaedic surgeon, took the lead ankle chapter; sports elbow and hand was transferred to in doing a major overhaul of this chapter. become part of the hand chapter; and spine injuries were • Chapter 4, “Sports Medicine”: Drs. Thompson and Miller moved to the spine chapter. Next we tackled the trauma spent a lot of time and much of the art budget in replacing the scrapbook images with new artwork, including com- chapter, shifting spine trauma to the spine chapter. Foot and posite images. ankle injuries distal to the tibial pilon were transferred to the • Chapter 5, “Adult Reconstruction”: Because we have foot and ankle chapter. Hand injuries were consolidated in recently broken up the topics of hip and knee arthroplasty the already great hand chapter. And, appropriately, some for MRC, we took a similar approach for this chapter, and things were left the same. We continued the popular high- it is new and improved as a result. Advances in shoulder lighting of key points and use of highlighter icons for impor- arthroplasty are also incorporated. tant figures. We also kept the end of chapter Testable Concepts • Chapter 6, “Disorders of the Foot and Ankle”: Dr. Kadaka summaries, which residents have told us are invaluable for took the lead on expanding and revitalizing this part of the last minute test preparation. book. It is more organized and includes great new images. Finally, above all else, we have made every attempt to • Chapter 7, “Hand, Upper Extremity, and Microvascular maintain C.C. Colton’s mantra from the preface of the first Surgery”: Drs. Chhabra and Brunton took one of the best chapters from the last edition and made it even better. edition of Miller’s Review of Orthopaedics: “The writer does the • Chapter 8, “Spine”: We invited Dr. Shen, new MRC lec- most who gives the reader the most knowledge and takes from turer (and veteran AAOS lecturer), to work on this chapter, him the least time.” and he made major changes, including tripling the number of images. We would be remiss if we did not recognize Mark D. Miller, MD the former spine chapter author, the late Dr. William Stephen R. Thompson, MD, MEd, FRCSC ix 1 CHAPTER BASIC SCIENCES Matthew R. Schmitz, Marc McCord DeHart, Zain Qazi, and Franklin D. Shuler CONTENTS SECTION 1 ORTHOPAEDIC TISSUES, 1 SECTION 3 PERIOPERATIVE AND ORTHOPAEDIC Bone, 1 MEDICINE, 105 Joints, 40 Perioperative Problems, 105 Neuromuscular and Connective Tissues, 69 SECTION 4 OTHER BASIC PRINCIPLES, 119 SECTION 2 ORTHOPAEDIC BIOLOGY, 83 Imaging and Special Studies, 119 Cellular and Molecular Biology, 83 Biomaterials and Biomechanics, 124 Infections and Microbiology, 94 TESTABLE CONCEPTS, 142 SECTION 1 ORTHOPAEDIC TISSUES • Have more endoplasmic reticulum, Golgi apparatus, BONE and mitochondria than do other cells (for synthesis ■ Histologic features of bone and secretion of matrix) ■ Types (Figure 1-1, Table 1-1) • RUNX2 is a multifunctional transcription factor that • Normal bone: lamellar or mature; either cortical or directs mesenchymal cells to the osteoblast lineage. cancellous • Bone surfaces lined by more differentiated, • Immature and pathologic bone: woven; more random, metabolically active cells more osteocytes, increased turnover, weaker • “Entrapped cells”: less active cells in “resting • Lamellar bone is stress oriented; woven bone is not. regions”; maintain the ionic milieu of bone • Cortical (compact) bone • Disruption of the active lining cell layer activates • Constitutes 80% of the skeleton entrapped cells. • Consists of tightly packed osteons or haversian systems • Two main functions: • Connected by haversian (or Volkmann) canals • Form bone • Contains arterioles, venules, capillaries, nerves, • Regulate osteoclastic activity possibly lymphatic channels • Osteoblast differentiation: • Interstitial lamellae: between osteons • Bone morphogenetic protein (BMP) stimulates • Fibrils connect lamellae but do not cross cement mesenchymal cells to become osteoprogenitor cells. lines. • Core-binding factor α-1 stimulates differentiation. • Cement lines define the outer border of an osteon. • β-Catenin stimulates differentiation into • Bone resorption has stopped and new bone osteoblasts, with resulting intramembranous bone formation has begun. formation. • Nutrition provided by intraosseous circulation • Platelet-derived growth factor (PDGF) through canals and canaliculi (cell processes of • Insulinlike growth factor (IGF) osteocytes) • Receptor-effector interactions in osteoblasts • Characterized by slow turnover rate, higher Young’s (Table 1-2) modulus of elasticity, more stiffness • Osteoblasts produce the following: • Cancellous bone (spongy or trabecular bone) • Alkaline phosphatase • Less dense, more remodeling according to lines of • Osteocalcin (stimulated by 1,25 stress (Wolff’s law) dihydroxyvitamin D) • Characterized by high turnover rate, smaller Young’s • Type I collagen modulus, more elasticity • Bone sialoprotein ■ Cellular biology (Figure 1-2) • Receptor activator of nuclear factor (NF)-κB • Osteoblasts ligand (RANKL) • Appear as cuboid cells aligned in layers along • Osteoprotegrin—binds RANKL to limit its immature osteoid activity • Derived from undifferentiated mesenchymal stem • Osteoblast activity stimulated by intermittent cells (pulsatile) exposure to parathyroid hormone (PTH) 1 2 Basic Sciences Cortical Immature Cancellous Pathologic (giant cell tumor) Haversian canal Cement line Interstitial lamellae Canaliculi Osteocyte CORTICAL BONE DETAIL FIGURE 1-1 Types of bone. Cortical bone consists of tightly packed osteons. Cancellous bone consists of a meshwork of trabeculae. In immature bone, unmineralized osteoid lines the immature trabeculae. Pathologic bone is characterized by atypical osteoblasts and architectural disorganization. (Colorized from Brinker MR, Miller MD: Fundamentals of orthopaedics, Philadelphia, 1999, WB Saunders, p 2.) Table 1-1 Types of Bone MICROSCOPIC APPEARANCE SUBTYPES CHARACTERISTICS EXAMPLES Lamellar Cortical Structure is oriented along lines of stress Femoral shaft Strong Cancellous More elastic than cortical bone Distal femoral metaphysis Woven Immature Not stress oriented Embryonic skeleton Fracture callus Pathologic Random organization Osteogenic sarcoma Increased turnover Fibrous dysplasia Weak Flexible Modified from Brinker MR, Miller MD: Fundamentals of orthopaedics, Philadelphia, 1999, WB Saunders, p 1. • Osteoblast activity inhibited by tumor necrosis • Certain antiseptics toxic to cultured osteoblasts: factor (TNF)-α • Hydrogen peroxide • Wnts are proteins that promote osteoblast • Povidone-iodine (Betadine) survival and proliferation. • Bacitracin (believed to be less toxic) • Deficient wnt causes osteopenia; excessive wnt • Osteocytes (see Figure 1-1) expression causes high bone mass. • Maintain bone • Wnts can be sequestered by other secreted • Constitute 90% of the cells in the mature skeleton molecules such as sclerostin (Scl) and • Former osteoblasts surrounded by newly formed dickkopf-related protein 1 (dkk1). matrix