James Robinson PhD, MPH

• Professor, Division Head, Health Policy and Management

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Sterile dressings are applied while an assistant simultaneously maintains the foot dorsiflexed with tension on the suture women's health week 2013 cheap xeloda line. The distal foot and ankle portion of a toe-to-groin cast is applied menstruation 3 times in a month purchase xeloda overnight, while ensuring that the suture ends of the tendon are in tension menstrual weight fluctuation order xeloda american express. However breast cancer lumps feel like purchase xeloda in india, a high rate of pressure sores has led us to consider alternative fixation women's health clinic waco tx order xeloda 500mg without a prescription. To prevent plantar pressure sores menstruation 6 weeks after giving birth 500mg xeloda free shipping, make sure the plaster is sufficiently hardened. Some surgeons will perform the exact procedure except transfer the whole tendon into the cuboid. These surgeons choose this insertion site if the foot has a concurrent fixed forefoot deformity and mild hindfoot varus that they choose not to correct. We prefer to correct the fixed deformity and transfer the anterior tibialis into the lateral cuneiform as we fear overcorrection from the more lateral insertion into the cuboid. Some surgeons add a third incision at the anterior distal tibia directly over the anterior tibialis tendon and just lateral to the tibial crest. The tendon sheath is incised here and the freed distal tendon end is pulled with a hemostat into this incision. From this incision, the freed distal tendon end is eventually pulled into the lateral incision for attachment. Attaching the Transferred Tendon A drill bit is selected to be slightly larger than the diameter of the sutured anterior tibialis tendon end. Once the bit is selected, make a hole directly in the center of the lateral cuneiform, drilling just through the plantar aspect of the bone (dorsal to plantar while aiming for the arch of the foot). While the foot is maximally dorsiflexed and everted, the suture needles are passed through the lateral cuneiform drill hole and out through the plantar aspect of the foot, guiding the tendon through the drill hole. This is a critical step: be certain that the tendon reliably enters the anchoring hole after the skin is closed when the foot is dorsiflexed and when the suture is tensioned. The suture needles on the plantar aspect of the foot are passed through a nonadhesive dressing (eg, Adaptic) and a sterile felt pad. At this time it is advisable to irrigate and close all other associated wounds, leaving the lateral recipient wound for last. This way the surgeon can ensure that the anterior tibialis is in the intended position just before dressing and cast application. The suture ends of the tibialis anterior tendon are threaded onto Keith needles and passed into the drill hole through the plantar aspect of the foot. The periosteum of the third cuneiform is sutured with interrupted nonabsorbable sutures into the transferred tibialis anterior tendon. The cast is molded and hardened with the foot in dorsiflexion and eversion and with the suture ends under appropriate tension. The suture is tied over a button on the exterior of the hardened cast to prevent plantar pressure sores. Dissection is carried down through subcutaneous tissues and the inferior limb of the inferior extensor retinaculum to expose the tendon sheath. The anterior tibialis tendon sheath is incised sharply and opened as far distally as possible and then proximally to just short of the ankle retinaculum. The lateral half of the anterior tibialis tendon insertion is detached as far distally as possible to gain maximum length of tendon for the transfer. A strong absorbable suture (eg, 1-0 Vicryl) is woven in a Bunnell-type fashion through the lateral half of the anterior tibialis tendon. The suture is grasped and pulled, allowing the lateral tendon to be gently dissected proximally but not beyond the ankle retinaculum. A cruciate periosteal incision is made directly over the cuboid, carefully avoiding the adjacent joint articulations. 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. Use the hemostat to develop a tract for the transfer of the anterior tibialis tendon. The hemostat is passed into this same tract into the medial wound to grasp the suture ends and bring the split anterior tibialis tendon into the lateral wound. Fixation of the Tendon to Bone While the foot is maximally dorsiflexed and everted, the suture needles are passed through the cuboid drill hole and out through the plantar aspect of the foot, guiding the tendon through the drill hole. The suture needles are passed through a nonadhesive dressing (eg, Adaptic) and a sterile felt pad. The periosteum of the cuboid is sutured with two interrupted absorbable sutures to the transferred split anterior tibialis tendon. Sterile dressings are applied, while ensuring that the felt pad is flush with the plantar skin and the suture ends of the tendon are at hand. Alternative fixation may include use of suture anchor into the cuboid or transfer of the lateral half of the tendon into the peroneus tertius tendon prior to its insertion into base of the fifth metatarsal. Fennell and Phillips4 suggest releasing the proximal medial insertion on the cuneiform instead of the distal lateral insertion on the first metatarsal to avoid this proximal crossing over, allowing for a more direct line of pull of the muscle on the transferred tendon. Flexibility of the foot is the main condition for a successful surgical result, because the surgical procedure is based on the dynamic muscle imbalance of the forefoot. Positioning Tendon harvest Too short a tendon can make transfer difficult, so the surgeon should obtain as much length as possible. Bowstringing and weakness by inadvertently cutting the extensor retinaculum should be avoided. The surgeon should attach a suture to the released tendon to allow ease of handling and passing. Tendon fixation It may be difficult to locate the lateral cuneiform in small children. An absorbable suture is used to hold the tendon as it usually dissolves and weakens by 6 weeks. Overcorrection can be avoided with insertion of the full tendon transfer along the third metatarsal axis. For the split tendon transfer, the optimal site for insertion to obtain maximal dorsiflexion in biomechanical studies is along the fourth metatarsal axis. Alternative forms of fixation may be considered in older children with large bones, such as a suture anchor. Wound closure All wounds are closed except the recipient site to be sure that the transferred tendon stays in the tunnel. Also, the foot is kept in maximum dorsiflexion during final wound closure and casting. Cast management Pressure sores on the bottom of the foot can result from too much tension on the button. Swelling and pressure sores may result if extensive and lengthy procedures are done. In these cases, prophylactic dorsal splitting of the cast in the operating room is important. In their two series of patients reviewed at the end of skeletal growth, none of the operated patients had further relapse. Foot alignment is restored after full-thickness anterior tibialis tendon transfer in the right foot. Tibialis anterior tendon transfer for residual dynamic supination deformity in treated clubfeet. The split anterior tibial tendon transfer in the treatment of spastic varus hindfoot of childhood. Analysis of the components of residual deformity in clubfeet presenting for reoperation. At 6 weeks, the button and suture are removed and the patient is allowed to begin walking. At 6 weeks, the button is removed and patient is placed in a short-leg walking cast for an additional 3 weeks to ensure healing and to avoid tendon rupture. Clinical and radiographic assessment of outcomes is performed at the end of healing. Clinical examination of the foot during active dorsiflexion demonstrates the new insertion site of the anterior tibialis tendon. Twenty-seven previously treated clubfeet in 25 patients were retrospectively evaluated after tibialis anterior tendon transfer to correct residual dynamic supination deformity. Clinical and radiographic improvement in both forefoot adduction and supination was demonstrated in 71 cases of residual dynamic congenital clubfoot deformity treated by full and Part 5 Chapter 1 Chapter 2 Oncology the Knee Overview of Musculoskeletal Tumors and Preoperative Evaluation 1695 Biopsy of Musculoskeletal Tumors 1719 Chapter 3 Overview of Endoprosthetic Reconstruction 1728 Chapter 4 Expandable Prostheses 1740 Chapter 5 Surgical Management of Metastatic Bone Disease: General Considerations 1749 Chapter 6 Cryosurgical Ablation of Bone Tumors 1757 Chapter 7 Overview of Resections Around the Shoulder Girdle 1766 Chapter 8 Total Scapular Resections With Endoprosthetic Reconstruction 1776 Chapter 9 Proximal Humeral Resection With Allograft Prosthetic Composite 1786 Chapter 10 Proximal Humerus Resection With Endoprosthetic Replacement: Intra-articular and Extra-articular Resections 1793 Chapter 11 Distal Humeral Resection With Prosthetic Reconstruction 1807 Chapter 12 Surgical Management of Metastatic Bone Disease: Humeral Lesions 1816 Chapter 13 Axillary Space Exploration and Resections 1825 Chapter 14 Forequarter Amputation 1833 Chapter 15 Above-Elbow and Below-Elbow Amputations 1842 Chapter 16 Primary and Metastatic Tumors of the Spine: Total En Bloc Spondylectomy 1846 Chapter 17 Overview on Pelvic Resections: Surgical Considerations and Classifications 1855 Chapter 18 Surgical Technique for Resection and Reconstruction of Supra-acetabular Metastatic Lesions 1873 Chapter 19 Buttockectomy 1876 Chapter 20 Surgical Management of Metastatic Bone Disease: Pelvic Lesions 1879 Chapter 21 Posterior Flap Hemipelvectomy 1891 Chapter 22 Anterior Flap Hemipelvectomy 1902 Chapter 23 Hip Disarticulation 1911 Chapter 24 Proximal and Total Femur Resection With Endoprosthetic Reconstruction 1917 Chapter 25 Distal Femoral Resections With Endoprosthetic Replacement 1929 Chapter 26 Proximal Tibia Resection With Endoprosthetic Reconstruction 1953 Chapter 27 Fibular Resections 1964 Chapter 28 the Use of Free Vascularized Fibular Grafts for Reconstruction of Segmental Bone Defects 1974 Chapter 29 Use of Allografts and Segmental Prostheses for Reconstruction of Segmental Bone Defects 1982 Chapter 30 Quadriceps Resections 1991 Chapter 31 Adductor Muscle Group (Medial Thigh) Resection 2000 Chapter 32 Hamstrings Muscle Group (Posterior Thigh) Resection 2005 Chapter 33 Overview of Surgical Resection of Space Sarcomas 2011 Chapter 34 Popliteal Resections 2018 Chapter 35 Soleus Resection 2023 Chapter 36 Surgical Approach and Management of Tumors of the Sartorial Canal 2028 Chapter 37 Surgical Management of Metastatic Bone Disease: Femoral Lesions 2034 Chapter 38 Foot and Ankle Amputations: Ray Resections 2047 Chapter 39 Creating an Above-Knee Amputation Stump After Hip Disarticulation 2053 Chapter 40 Above-Knee Amputation 2060 Chapter 41 Below-Knee Amputation 2067 Chapter 42 Foot and Ankle Amputations: Lisfranc/Chopart 2072 All figures courtesy of Martin M. Chapter 1 Overview of Musculoskeletal Tumors and Preoperative Evaluation Martin M. This chapter reviews the unique biologic behavior of soft tissue and bone sarcomas, which provides the basis for their staging and resection and the use of appropriate adjuvant treatment modalities. A detailed description of the clinical, radiographic, and pathological characteristics for the most common sarcomas is presented. Soft tissue sarcomas are classified according to the adult tissue that they resemble. Similarly, bone sarcomas usually are classified according to the type of matrix production: osteoid-producing sarcomas are classified as osteosarcomas, and chondroid-producing sarcomas are classified as chondrosarcomas. Tumors arising in bone and soft tissues have characteristic patterns of biologic behavior because of their common mesenchymal origin and anatomic environment. The grade is based on tumor morphology, extent of pleomorphism, atypia, mitosis, matrix production, and necrosis, with the two main factors being mitotic count and spontaneous tumor necrosis. Sarcomas form a solid mass that grows centrifugally, with the periphery of the lesion being the least mature. In contradistinction to the true capsule that surrounds benign lesions, which is composed of compressed normal cells, sarcomas usually are enclosed by a reactive zone, or pseudocapsule. 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. The thickness of the reactive zone varies according to the histogenic type and grade of malignancy. High-grade, and occasionally low-grade, may break through the pseudocapsule to form metastases, termed skip metastases, within the same anatomic compartment in which the lesion is located. These neoplasms represent less than 1% of all adult and 15% of pediatric malignancies. As of 2006, the annual incidence in the United States, which remains relatively constant, was approximately 6000 to 7000 soft tissue sarcomas and 2750 bone sarcomas. In 2006, the overall mortality rate was 30% for soft tissue sarcomas and 45% for bone sarcomas. In the past two decades, both survival and quality of life of patients with soft tissue and bone sarcomas have improved dramatically as a result of the multimodality treatment approach. Limb-sparing surgery, used in combination with chemotherapy and radiation therapy, can achieve cure in the majority of patients with soft tissue and bone sarcomas, and resection is performed in lieu of amputation in more than 90% of all patients. The most common bone sarcomas are osteosarcoma, chondrosarcoma, and Ewing sarcoma. A pseudocapsule of a high-grade soft tissue sarcoma (arrows) composed of compressed tumor cells and a fibrovascular zone of reactive inflammatory response. Unique features are formation of reactive zone, intracompartmental growth, and, rarely, the presence of skip metastases. Skip nodules are tumor foci not in continuity with the main tumor mass that form outside the pseudocapsule. The growth plate, although not invaded by the tumor in this case, is not considered an anatomic barrier to tumor extension, probably because of the numerous vascular channels that pass through the growth plate to the epiphysis. However, the articular cartilage is an anatomic barrier to tumor extension and very rarely is directly violated by a tumor. Although gross involvement of the epiphysis and medial cortical breakthrough and soft tissue extension are evident, the articular cartilage is intact. This phenomenon allows intra-articular resection of high-grade sarcomas of the distal femur in most cases. The tumor does not penetrate, looking in a clockwise direction, the lateral intermuscular septum, the adductor compartment, and the aponeuroses of the sartorius and rectus femoris muscles. It is only at a later stage that the walls of the compartment are violated (either the cortex of a bone or aponeurosis of a muscle), at which time the tumor breaks into a surrounding compartment. Typical anatomic barriers are articular cartilage, cortical bone, and fascial borders. Sarcomas are defined as intracompartmental if they are encased within an anatomic compartment. Most bone sarcomas are bicompartmental at the time of presentation; they destroy the overlying cortex and extend directly into the adjacent soft tissues. Joint involvement in sarcoma is uncommon, because direct tumor extension through the articular cartilage is rare. Metastatic Bone and Soft Tissue Sarcomas Unlike carcinomas, bone and soft tissue sarcomas disseminate almost exclusively through the blood. Hematogenous spread of extremity sarcomas is manifested by pulmonary involvement in the early stages and by bony involvement in later stages. Abdominal and pelvic soft tissue sarcomas, on the other hand, typically metastasize to the liver and lungs. Low-grade soft tissue sarcomas have a low (under 15%) rate of subsequent metastasis, whereas high-grade lesions have a significantly higher (over 20%) rate of metastasis. Ewing sarcoma of the distal two thirds of the femur (A) and osteosarcoma of the proximal tibia (B). Most high-grade bone sarcomas are bicompartmental at the time of presentation (ie, they involve the bone of origin as well as the adjacent soft tissues). Plain radiograph of the proximal femur revealed direct invasion through the cortical bone with a pathological fracture of the lesser trochanter (arrows). In surgery, exploration of the sciatic nerve revealed direct tumor involvement with extension under the epineural sheath. Extension of an osteosarcoma of the distal femur to the knee joint along the cruciate ligaments (arrow points to tumor); the articular cartilage is intact.

A talocalcaneal coalition is best seen on the Harris axial view menstruation unclean bible cheap xeloda 500 mg fast delivery, but it may be difficult to obtain the exact orientation to adequately visualize the middle facet women's health center santa fe buy xeloda 500 mg without a prescription. On the lateral view there may be a continuous C-shaped line along the talar dome and into the posterior facet (Csign) menstrual tumblr cheap xeloda 500mg with amex. Pain secondary to talocalcaneal coalitions usually develops between 12 and 16 years of age women's health issues in japan order xeloda toronto. This pain may be generalized to the midfoot or can be specifically localized to the medial aspect of the hindfoot and ankle menopause mood changes purchase xeloda line. The initial treatment for painful talocalcaneal coalitions is activity modification pregnancy 41 weeks purchase xeloda without a prescription, anti-inflammatory medication, and immobilization in a short-leg walking cast. The main goals of treatment are, primarily, elimination of pain and restoration of function. Restoration of arch height is unlikely following excision of a talocalcaneal coalition. Generally the leg assumes an external rotation posture at rest so that the medial ankle and hindfoot are easily accessible. If this is not the case, then a small bump can be placed beneath the opposite hip. A tourniquet is placed on the upper thigh or an eschmarch tourniquet may be used just proximal to the ankle. An examination of subtalar motion may be performed under anesthesia to compare to the motion obtained after excision of the coalition. The approach involves identification of the entire coalition with delineation of the normal cartilage on either side. The bone representing the coalition is exposed and subcutaneous fat or a portion of the flexor hallucis longus is interposed. A straight horizontal incision is made along the medial aspect of the hindfoot centered over the sustentaculum tali. If any fibers of the abductor hallucis are encountered, they are retracted plantarly. The flexor hallucis longus tendon sheath can be opened if it is to be used as interposition material. At this point all of the critical anatomic structures have been identified and the coalition can now be exposed. The posterior tibial tendon (superior) and flexor digitorum longus tendon (inferior). The neurovascular bundle is seen directly posterior to the posterior tibial tendon. While retracting the flexor digitorum longus tendon plantarly, palpate the sustentaculum tali. The coalition lies deep to the medial portion of the sheath of the flexor digitorum longus and periosteum. Because the normal joint in this area is now obscured by the coalition, it is often difficult to determine the appropriate level for bone resection without first identifying some normal joint space. If this is the case, the dissection may be carried posteriorly and anteriorly to identify the posterior and anterior facets of the subtalar joint, respectively, so that the normal articular cartilage in these areas can be identified. The posterior facet can be identified by retracting the neurovascular bundle either posteriorly or anteriorly and dissecting deep to it. The anterior facet is identified just proximal to the talonavicular joint and plantar to the talar neck. Occasionally a stripe of cartilage can be identified traversing through the center of the coalition. Next, while retracting the flexor digitorum longus and neurovascular bundle plantarly to protect them, the bone is resected between the two previously identified areas of normal articular cartilage. Take care to resect bone from known to unknown areas, as it is possible to drift dorsal or plantar into the body of the talus or calcaneus, consequently missing the coalition. Once the entire coalition has been resected, the foot should be inverted and everted, demonstrating an improvement in subtalar motion. It should be possible at this point to see clear space from the posterior facet to the anterior facet with supple motion through the joint. Apply a thin layer of bone wax to the exposed bony surfaces to minimize bleeding and theoretically decrease the risk of recurrence of the coalition. The medial aspect of the sheath of the flexor digitorum longus and the periosteum overlying the talus are incised. The posterior facet is visualized (just posterior to the curette) and the coalition is entered with a curette. The coalition has been removed and there is a visible gap between the talus (superior) and calcaneus (inferior). Retrocalcaneal fat is exposed between the Achilles tendon and the neurovascular bundle and harvested for the graft. The graft is inserted into the area of the resected coalition and the periosteum is closed over the graft. The flexor hallucis longus lies in a groove directly inferior to the sustentaculum tali. The flexor hallucis is then split longitudinally but left in continuity along its length. The superior half of the tendon is then placed in the gap that has been created where the coalition was resected. Care is taken to ensure that the length of tendon that is split is sufficiently long so that the motion of the flexor hallucis longus is not restricted. This is accomplished by moving the interphalangeal joint of the great toe through a range of motion and confirming that motion is not restricted. The periosteum from the talus is then sutured to the periosteum from the sustentaculum to prevent the tendon from slipping out of place. Excision of the coalition is contraindicated if greater than 50% of the joint surface is coalesced or in the presence of subtalar arthritis. Hindfoot alignment is determined clinically and radiographically to assess for hindfoot valgus. Approach Excision of coalition the incision should be long enough to allow adequate identification of normal subtalar joint. The periosteum and medial sheath of the flexor digitorum longus are preserved to secure the graft. The surgeon should identify normal articular cartilage posterior and anterior to the coalition so that the level of resection can be identified. Bone is resected from the area where the normal joint can be seen toward the center of the coalition. It is possible to resect bone into the body of the talus or calcaneus, missing the coalition, if careful attention is not paid to the level of resection. Closure the periosteum and medial sheath of the flexor digitorum longus tendon are repaired to prevent extrusion of the graft. The foot is immobilized and the patient should remain nonweight bearing for 2 to 3 weeks to allow for wound healing and consolidation of the graft. After that, progressive weight bearing and gentle range-ofmotion exercises are initiated, focusing on restoring subtalar motion. Interposition of the split flexor hallucis longus tendon after resection of a coalition of the middle facet of the talocalcaneal joint. Talocalcaneal coalition: diagnosis with the C-sign on lateral radiographs of the ankle. The so-called postural clubfoot is held by the infant in an equinovarus position, but all components are nearly completely correctable with gentle manipulation and resolve over time without intervention. A small proportion of clubfeet are teratologic, occurring as part of other neuromuscular diseases, such as Larsen syndrome, any of the arthrogryposis syndromes, and spina bifida. A severe type of idiopathic clubfoot, the complex clubfoot, has tighter hindfoot and plantar structures. Ignacio Ponseti began manipulating clubfeet through serial casting, completely correcting the clubfoot deformity. The principles of Ponseti casting lay in gradually stretching the soft tissue structures and gently inducing remolding of the primarily cartilaginous bones of the hindfoot during immobilization. For the definitive publication on clubfoot and the Ponseti technique, the reader is referred to Dr. Ponseti has recently published a modification to his original casting technique that addresses the specific deformities characteristic of the complex clubfoot. Left uncorrected, the weight-bearing surface in a clubfoot becomes the dorsolateral surface. Thick callosities develop, and the positioning of the foot creates significant functional disability. Half or more of clubfeet identified on second-trimester ultrasounds have an association with other anomalies or are syndromic. All children with clubfeet should be examined for other findings that may suggest a syndromic or neuromuscular association, such as other contractures or joint dislocations (especially hip dislocation), cutaneous lesions, spinal abnormalities, and abnormal facial features. The clubfoot is easily identified by the combined deformities of cavus, adductus, varus, and equinus. Consider complex clubfoot if a deep midfoot crease and cavus extend across the entire plantar aspect of the foot. A deep heel crease, a nonpalpable calcaneus, and tight varus and equinus may suggest complex clubfoot. The ability to abduct or dorsiflex the foot completely suggests etiologies other than idiopathic clubfoot, such as isolated metatarsus adductus, neuromuscular disease, or focal anatomic abnormalities. The fat pad of the heel will feel empty upon palpation due to equinus positioning of the calcaneus. The lateral head of the talus is easily palpable over the dorsolateral surface of the foot. Care must be taken in differentiating these two structures because Ponseti casting necessitates free motion of the calcaneus under a talus that is stabilized over its lateral head, whereas pressure at the calcaneal tuberosity blocks calcaneal rotation, allowing only forefoot abduction. The complex clubfoot has a crease that extends completely, or nearly so, across the plantar aspect of the foot. Relative to normal foot anatomy, the first ray is plantarflexed, generating the cavus deformity. By comparison, all rays are plantarflexed in the complex clubfoot, resulting in full-foot cavus. The navicular is medially displaced on the talus, and the cuboid is medially displaced on the calcaneus as part of the adductus deformity. The medial corners of the head of the talus and the anterior calcaneus are flattened. The calcaneus is inverted under the talus, creating the hindfoot varus, while also being in equinus and elevated in the fat-pad of the heel. In children with unilateral clubfoot, the affected foot is smaller, as is the lower leg, relative to the unaffected side. Nearly complete dorsiflexion (more than 20 degrees) is present, although abduction may be slightly limited. These feet may be thought of as "postural" in nature, and most will resolve spontaneously or with parental stretching over 1 to 2 months. If persistent, one or two casts usually correct the deformity, and no tenotomy is usually necessary because sufficient dorsiflexion is obtained with casting. Note the medial displacement of the navicular and cuboid, the inversion and internal rotation of the calcaneus under the talus, and equinus of the talus and calcaneus. It is important to examine the clubfoot before each casting to evaluate for the adjustments that must be made during casting to correct residual deformities or to identify, and modify casting for, a complex clubfoot. A number of classification systems have been introduced, the most commonly used being those of DiMeglio and Pirani. Both have utility in evaluating correction and recurrence, but the predictability of recurrence and final function is still unclear. Teratologic or syndromic clubfeet (including neuromuscular disorders) Clubfoot deformity may be more difficult to correct or may tend to recur. Ponseti casting can be performed successfully in children up to 2 years old, although any correction obtained by casting in older children may reduce the amount of surgery required for complete correction. An open tendo-Achilles lengthening may be more appropriate than a percutaneous tenotomy in children over 2 years old. A short-leg cast should be applied first so that attention is made solely to molding around the ankle before extending the cast above the knee. Padding should be minimal, and plaster is preferable for its ability to be molded precisely to the contours of the foot and ankle. Dorsiflexion of 10 degrees would appear to be sufficient to avoid Achilles tenotomy. Dorsiflexion of the metatarsals relative to the axis of the talus reveals the source of clinical dorsiflexion. The calcaneus is still in equinus (relative to the tibial axis) and a percutaneous Achilles tenotomy is required to complete the correction. The calcaneus is dorsiflexed and the axis of the first metatarsal is almost parallel to the axis. Forced-dorsiflexion lateral radiograph of the right foot 3 weeks after the percutaneous Achilles tenotomy. Now the calcaneus is dorsiflexed relative to the tibial axis and what was seen on the pretenotomy radiograph (B). Purple discoloration of toes after application of the first cast, as the cast begins to cool.

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The contraindications to limb-sparing resection are as follows: Groin involvement womens health 5k running guide purchase on line xeloda. Tumors arising or involving the groin and femoral triangle often cannot be reliably resected and may require amputation women's health clinic savannah ga order xeloda 500 mg line. If two muscle groups have to be completely removed womens health partners effective xeloda 500mg, the extremity may not be functionally salvageable women's health ketone diet 500 mg xeloda fast delivery. Large tumors of the anterior thigh may involve the adductor group as well as the posterior muscle group by passing through the linea aspera or the intermuscular septum women's health clinic flinders buy generic xeloda 500 mg. On rare occasions breast cancer 88 year old woman purchase xeloda 500mg without prescription, large tumors of the proximal thigh and groin extend below the inguinal ligament into the retroperitoneal space, necessitating amputation. Recurrent tumors of the quadriceps, infection, extensive tumor hemorrhage, or extensive tumor contamination from previous surgical procedures may require amputation. Neurovascular involvement of the tumor does not necessarily obviate limb-salvage resections. Most tumors of the quadriceps muscle will displace but not invade the superficial femoral or common femoral arteries. If the surgical margins are positive for tumor cells or extremely close, resection of the involved artery and replacement with a vascular graft often allows limb salvage. The surgical manipulation of the muscle flap must not interrupt its circulation; therefore, a precise knowledge of the location and pattern of the vascular pedicles is required. Each pedicle provides circulation to a portion of the muscle, and division of more than three pedicles during the elevation of the flap may result in distal muscle necrosis. Complete elevation of the muscles is possible when the dominant proximal vascular pedicles are preserved. Tumors may remain within one muscle belly or involve several components of the quadriceps muscle. It is important to identify the relationship between the tumor and the underlying femur. Tumors that involve the vastus medialis very often involve the adjacent periosteum as well. Bone Scan A three-phase bone scan is useful to determine the proximity of the tumor to the periosteum. This does not make quadriceps tumors unresectable but indicates that the underlying periosteum must be removed during the surgical procedure. It is important to determine the anatomic relations of these vessels to the tumor before resection. Large tumors of the proximal thigh may require ligation of the profundus femoris artery and vein; therefore, knowing before surgery whether the superficial artery is patent is essential. This is particularly true in the older patient, in whom the superficial femoral artery may be occluded secondary to peripheral vascular disease. Displacement of the superficial femoral artery usually does not indicate direct tumor extension; however, if the surgical margins are positive, the artery should be resected and replaced with a saphenous or artificial graft. Areas that major arteries and veins traverse should be avoided so that the vessels are not penetrated, risking tumor cell contamination. Muscle transfers for type A resection (vastus lateralis with or without vastus intermedius). The long head of the biceps femoris is transferred anteriorly and sutured to the patella, the quadriceps tendon, and the rectus femoris muscle. Muscle transfers for type B resection (vastus medialis with or without vastus intermedius). The sartorius muscle is transferred anteriorly but not detached from its distal insertion and is sutured to the patellar tendon, patella, quadriceps tendon, and rectus femoris muscle. The sartorius muscle is mobilized anteriorly and sutured to the patella and the remains of the quadriceps tendon. The biceps femoris laterally and the sartorius and semitendinosus medially are transferred anteriorly, tenodesed to each other, and sutured to the patella. There are five patterns of vascular supply to muscles, based on the distribution of major and minor vascular pedicles. Preoperative picture of a patient with a large malignant soft tissue sarcoma in the lateral aspect of the anterior compartment of the thigh. Resection includes the vastus lateralis and part of the vastus intermedius and rectus femoris. The long head of the biceps femoris is transferred anteriorly and sutured to the patella and the remains of the quadriceps tendon and rectus femoris. A longitudinal skin incision just above the tumor mass is made, encompassing the biopsy site. The tumor mass should be resected en bloc with 1 cm of surrounding healthy tissue. For tumors that involve the vastus medialis, vastus lateralis, or rectus femoris, the superficial margins are the skin and subcutaneous tissues and the deep margins may include part of the vastus intermedius. The superficial margins of tumors that involve the vastus intermedius may include part of one of the vasti or rectus femoris. If the deep surface of the tumor is close to the bone, the periosteum should be peeled off and resected and the superficial cortex removed with a high-speed burr (Midas). Flaps composed of skin and subcutaneous tissue are made just superficial to the fascia lata. They extend to the adductor muscle group medially and to the greater trochanter and flexor muscles laterally. In the area of the canal of Hunter, while strong lateral traction is placed on the sartorius muscle, muscular insertions from the adductor magnus muscle coursing over the superficial femoral artery are identified. By electrocautery the tensor fascia lata muscle is released from its origin on the wing of the ilium. Then the origin of the sartorius muscle on the anterior superior iliac spine is identified and divided. The origins of the vastus lateralis, vastus intermedius, and vastus medialis on the femur are transected from the bone using electrocautery. One cannot avoid transecting both the prepatellar and quadriceps (postpatellar) bursae. The insertion of the vastus medialis into the medial collateral ligament is likewise divided, and the specimen is then free. The incision extends longitudinally from the anterior inferior iliac spine to the patella. If physical examination or tomography shows that the tumor encroaches on the patella, this bone and its tendon should also be excised. If this clinical situation arises, the incision should be continued over the knee to the tibial tubercle. They extend to the abductor muscle group medially and to the greater trochanter and flexor muscles laterally. The inguinal ligament and the femoral triangle are uncovered, exposing the common femoral artery and vein and the femoral nerve. Lateral traction is placed on the quadriceps muscle group so that muscular branches coming from the superficial femoral artery and vein into the quadriceps muscle are exposed. Working from cranial to caudal, these vessels are clamped, divided, and ligated; included are the profunda femoris artery and vein. In the area of the canal of Hunter, when strong lateral traction is placed on the sartorius muscle, muscular insertions from the abductor magnus muscle coursing over the superficial femoral artery are identified. These muscle fibers should be divided as they cross the superficial femoral artery. A plane beneath the tensor fascia lata muscle and above the gluteus medius and minimus is identified. The origin of the rectus femoris muscle on the anterior inferior iliac spine is likewise identified and divided through its tendinous portion. Origins of the vastus lateralis, vastus intermedius, and vastus medialis on the femur are transected from bone by using electrocautery. Using strong upward and medial traction on the specimen, the insertions of the vastus lateralis, vastus medialis, and rectus femoris into the patellar tendon are divided on the patella bone. The dissection site is copiously irrigated, and any bleeding points are secured with ligatures or electrocautery. To facilitate rehabilitation by helping to provide stability to the knee, the gracilis muscle medially and the short head of the biceps muscle laterally are transected at their insertions on the medial and lateral collateral ligaments. This transection should be as far distal as possible so that a tendinous portion of the muscle is retained. Then, using heavy nonabsorbable sutures, these two muscles are transplanted onto the patellar tendon. The muscles are approximated in the midline to cover the distal third of the femur. Suction catheters are placed beneath the skin flaps and the subcutaneous tissue is approximated. The patient may begin ambulation when the suction catheters have been removed and edema of the leg has resolved. Because the lymphatics along the superficial femoral artery and within the buttock remain intact, prolonged swelling is not usually a problem, serous drainage from transected muscle bundles does not occur in large amounts. Several millimeters of the outer cortex can be removed; however, the outer cortex itself should not be removed en bloc. Suction catheters are placed beneath the skin flaps and the subcutaneous tissue is approximated with interrupted absorbable sutures. Another technique that can be used to functionally reconstruct large defects (which is not within the scope of this textbook) is latissimus dorsi microvascular transplantation. This transection should be as far distal as possible to retain a tendinous portion of the muscle. The muscle is transferred anteriorly to the midline so that it will have an almost direct line of pull. Then, using heavy, nonabsorbable sutures, the muscle is transplanted onto the patella and the remains of the quadriceps tendon and rectus femoris. Sartorius Muscle Transfer Semitendinosus Muscle Transfer the muscle is transected as far distal as possible from its insertion to the proximal tibia and transferred anteriorly so that it will have an almost direct line of pull. The muscle and its tendinous part are then sutured to the patella and the remains of the quadriceps. After completion of the resection, the sartorius muscle is released, but not transected, from its distal insertion on the medial aspect of the proximal tibia. The aim is to transfer the muscle anteriorly to the midline to achieve a straight line of pull between its origin on the anterior superior iliac spine and the patella. After ligating only two or three distal vascular branches, the sartorius can easily be transferred toward the midline and sutured to the patellar tendon, the patella, and the remains of the quadriceps tendon. Tumors that are close to the groin or the origin of the quadriceps require a careful dissection of the femoral triangle. Tumors that arise close to the insertion of the quadriceps muscles may require an intra-articular resection and removal of a portion of the adjacent knee capsule. The preoperative imaging studies must be carefully evaluated before an attempted resection. Large defects after quadriceps resection can be reconstructed using various muscle transfers primarily. If radiation therapy is planned postoperatively, it is best to postpone any transfers until the radiation is completed for optimal function of the transferred muscle. Tumors that arise within the vastus medialis muscle may extend and displace the sartorial canal. This should be determined preoperatively and mandates exploration and mobilization of the superficial femoral vessels and contents of the canal. If muscle transfer reconstruction was performed, a knee extension brace is initially used and an intensive physical therapy program for muscle strengthening and knee range of motion is started 3 to 4 weeks postoperatively. No immobilization is required if only resection was carried out, and patients may gradually begin ambulation when the suction catheters have been removed. Because the lymphatics along the superficial femoral artery and within the buttock remain intact, prolonged swelling is not usually a problem. There are limited data regarding the functional outcomes of patients who undergo extensive resections of the quadriceps muscle with or without reconstruction. Markhede and Stener5 evaluated the postoperative function in 17 patients who underwent quadriceps muscle resections. They found that the isometric strength of the muscle decreased by 22%, 33%, 55%, and 76% when one, two, three, or more components of the quadriceps muscle were resected, respectively. They concluded that the degree of quadriceps resection has a strong impact on functional outcome. Malawer4 performed a gait electromyographic analysis on a patient who underwent distal femoral resection, endoprosthetic replacement, and extensor mechanism reconstruction with the sartorius and biceps femoris muscles. Six months after the operation, both muscles were recruiting in phase with the rectus femoris of the same limb. According to our experience, most patients who undergo muscle transfer functional reconstruction have good to excellent functional outcomes and satisfactory active range of motion. Knee stiffness is the most common problem and is easily treated by physical therapy. The effect of quadriceps excision on functional results after distal femoral resection and prosthetic replacement of bone tumors. Restoration of quadriceps femoris function with a dynamic microsurgical free latissimus dorsi transfer. Functioning muscle transplantation after wide excision of sarcomas in the extremity.

Reduction women's health center houston order xeloda overnight, Fixation menopause drugs discount xeloda 500mg, and Repair Preset transfixation Kirschner wires as previously described women's health clinic lubbock order on line xeloda. The volar approach facilitates the reduction by allowing direct access to the lunate menstrual cramps 7 months pregnant buy xeloda online pills. Often the tenosynovium surrounding the tendons within the carpal tunnel is thickened menopause joint pain relief buy xeloda 500 mg on line. A volar menstrual twice in one month buy xeloda with mastercard, semilunar, apex-distal, capsuololigamentous rent is visible at the space of Poirer. Although not a surgical emergency, definitive stabilization should be carried out as soon as possible for technical ease and improved postoperative outcomes, especially in the presence of median nerve symptoms. The ever-elusive lunate may be stabilized during reduction by placing the thumb through the dorsal incision and the index finger through the volar incision (when a dual-incision approach is used). The bony architecture should be reduced and stabilized in an anatomic position before capsuloligamentous repair. Overtensioning of the soft tissues by repairing them first may prevent accurate reduction of the carpus. Active and passive digital range-of-motion exercises are encouraged immediately to prevent flexor tendon adhesions and digital stiffness. Sutures are removed at 10 to 14 days and full-time cast or splint immobilization is continued for a total of 8 weeks postoperatively. Pins may be removed at 8 weeks, and the patient may be converted to a removable splint to promote range of motion of the wrist. Perilunate dislocations and fracture dislocations: closed and early open reduction compared in 28 cases. Perilunate dislocation and fracture dislocation: a critical analysis of the volardorsal approach. It arises from the distal aspect of the sigmoid notch of the radius and inserts into the base of the ulnar styloid. As a result of this anatomic configuration, they function as a unit rather than as independent ligaments. This is reversed with pronation as the ulna moves distally, causing it to become ulnar-positive. The ulnar head also moves within the sigmoid notch in a dorsal direction with pronation and a volar direction with supination. The lesions are more common with ulnar-positive and neutral patients and are frequently found in patients with fractures of the distal radius. Several authors have examined the incidence of intracarpal soft tissue injuries associated with distal radial fractures. These lesions result in ulnar carpal instability with volar translocation of the carpus. Isolated disc tears should be differentiated from disruption of the dorsal and volar radioulnar ligaments. Degenerative and traumatic lesions can coexist, and injury can render a degenerative lesion symptomatic. The initial physical examination reveals swelling over the ulnar aspect of the wrist with inflammation of the tendon of the extensor carpi ulnaris. Significant instability can present as laxity of the distal ulna with a positive "piano key" sign and dorsal prominence of the distal ulna. This may be due to a significant tear or detachment of the dorsal or volar radioulnar ligaments. A visual carpal supination deformity with ulnar prominence that can be passively corrected by a dorsally applied force to the pisiform indicates an ulnar extrinsic ligament tear. The examiner must therefore evaluate all of the commonly injured structures on the ulnar side of the wrist. This would cause tenderness over the lunatotriquetral interval with a positive shuck test (painful click as the lunate and triquetrum slide abnormally). An audible clunk and visual subluxation of the carpus that occur with active ulnar deviation suggest that a midcarpal instability is present. Crepitus and pain over the pisotriquetral joint on the shear test may indicate pisotriquetral arthritis. The other soft tissue structures around the ulnar wrist should be examined, including the ulnar nerve, the dorsal ulnar sensory nerve branch, and the ulnar artery. Grip strength measurements using a Jamar dynamometer, while subjective, are helpful in quantitating patient effort and as a parameter to follow therapeutic progress. This will allow assessment for fracture, ligament instability resulting in carpal malalignment, and ulnar variance. After immobilization, a therapy program involving rangeof-motion exercises and gradual strengthening is initiated. If there is ongoing synovitis, a well-placed cortisone shot can further help to quiet this inflammation. If the styloid remains displaced, then open reduction and internal fixation is required. The algorithm for the treatment of degenerative type 2 tears proceeds from arthroscopy to ulnar-shortening osteotomy (see Chaps. Preoperative Planning All physical examination findings and radiographic study results must be reviewed. Examination under anesthesia is performed, including the tests discussed earlier, before positioning in the arthroscopy tower. The specific treatment for each traumatic class 1 lesion is determined by the type of tear found arthroscopically. Arthroscopic treatment has become increasingly the method of choice for many traumatic lesions. Open the sixth extensor compartment radially for 1 cm and retract the extensor carpi ulnaris ulnarly, providing access to its subsheath. The suture is tied either under the skin over the dorsal wrist capsule (preferred) or out of the skin over a bolster. I have not found a significant difference between use of a short-arm splint and use of a long-arm or sugartong splint in regard to healing and outcome. Unlike a central tear, fibrous tissue and incomplete healing obscure the actual tear. Base the method of fixation (longitudinal Kirschner wire, screw, bone anchor, or tension band) on fragment size and surgeon comfort. The wires must exit the radius on its radial border, just volar to the first extensor compartment. An incision is made over the exiting Kirschner wire to retract and protect the radial sensory nerve and the tendons of the first extensor compartment. The placement of the needles into the predrilled holes can be challenging since the holes are not visible by the scope in the 3-4 portal. Burring of the attachment site along the sigmoid notch of the radius to bleeding bone is necessary to introduce additional vascularity and promote wound healing. Range-of-motion exercises are then progressed, using a removable splint for protection initially. The microvasculature of the triangular fibrocartilage complex: its clinical significance. Accuracy of direct magnetic resonance arthrography in the diagnosis of triangular fibrocartilage complex tears of the wrist. Peripheral tears of the triangular fibrocartilage complex cause distal radioulnar joint instability after distal radial fracture. Ulnar shortening combined with arthroscopic repairs in the delayed management of triangular fibrocartilage complex tears. There is no consensus regarding the definition of clinically significant instability, though various radiographic criteria have been used. As each radioulnar ligament passes ulnarly, it divides in the coronal plane into two limbs. The radius of curvature of the sigmoid notch is much greater than the radius of curvature of the ulnar head. Patients with chronic instability may report a clunk at the wrist with forearm rotation. Pain and weakness is exacerbated by activities requiring forceful rotation while gripping, such as turning a screwdriver. A thorough patient examination should include the following tests: Passive translation ("piano key" sign). The addition of applied stress to the joint during imaging may aid in detection of subtle instability. In such patients, all attempts at conservative management should be exhausted before considering surgery. The technique described creates stability by nearanatomic reconstruction of the dorsal and volar radioulnar ligaments. If present, osseous malalignment must be addressed at the time of ligament reconstruction to obtain a good result. Intra-articular radioulnar ligament reconstruction requires a competent sigmoid notch for success. A notch that is developmentally flat or that has posttraumatic deficiency of either rim should be treated with a sigmoid notch osteoplasty at the time of ligament reconstruction. Soft tissue reconstruction in the presence of substantial residual bony deformity or arthritis will yield poor results. Positioning the patient is positioned supine with the affected limb resting on a hand table. Alternatively, a strip of the flexor carpi ulnaris tendon can be harvested using a tendon stripper through the same volar incision for graft passage. The palmaris tendon can be brought into relief by having the patient touch the thumb and small fingers while flexing the wrist slightly. The tunnel should be parallel to the articular surfaces of both the sigmoid notch and lunate fossa. Standard drill bits may be used to enlarge the bone tunnels to accommodate the previously harvested graft. The probe indicates the location of the fovea on the ulnar head where the drill should exit. Dissection is carried down between the ulnar neurovascular bundle and finger flexor tendons to reach the volar surface of the radius. A suture passer travels through the radial bone tunnel (dorsal to volar) to retrieve one limb of the graft (indicated by a red vessel loop). 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 two graft limbs are pulled taut and a half-hitch knot is made against the dorsal aspect of the ulnar neck. If concurrently performing a corrective osteotomy, make the bone tunnels before completing the osteotomy. At the first postoperative visit, the patient is transitioned to a long-arm cast for 3 weeks. At 4 weeks postoperatively, the patient is placed in a wellmolded short-arm cast for an additional 2 weeks. At 6 weeks after surgery, the cast is changed to a removable splint, which is worn for an additional 4 weeks. The patient should be able to return to most activities by 4 months after surgery, but heavy lifting and impact loading are avoided until 6 months postoperatively. Teoh and Yam12 reported similar results, with restoration of stability in seven of nine patients using a similar reconstructive method. The effect of dorsally angulated distal radius fractures on distal radioulnar joint congruency and forearm rotation. The stabilizing mechanism of the distal radioulnar joint during pronation and supination. Most patients experience decreased pain and improved strength and stability while maintaining near-normal range of motion. The described technique effectively restored stability in 12 of 14 patients while providing about 85% of the strength and range of motion of the contralateral unaffected side. Distal radioulnar instability is an independent worsening factor in distal radial fractures. Stress computed tomography analysis of the distal radioulnar joint: a diagnostic tool for determining translational motion. A cadaveric study of the anatomy and stability of the distal radioulnar joint in the coronal and transverse planes. Chapter 51 Extra-articular Reconstructive Techniques for the Distal Radioulnar and Ulnocarpal Joints Christopher J. It consists of fibers originating from the subsheath of the extensor carpi ulnaris, the ulnocarpal ligaments, the dorsal and palmar radioulnar ligaments, and the triangular fibrocartilage proper. It is continuous with the palmar carpal ligament and shares connecting fibers with the flexor retinaculum just proximal to the pisiform. The extensor retinaculum attaches to the pisiform and triquetrum medially and to the lateral margin of the radius laterally. The triangular fibrocartilage proper originates from the radius medially and attaches to the base of the ulnar styloid.