Treatment

Disease /treatment Nonsurgical Surgical

Occipitocervical provisional stabilization while avoiding traction posterior occipitocervical fusion (C0 - C2 or lower)
Instability & indications indications
Dislocation traumatic instability with distraction of the most traumatic cases require stabilization
occipitoatlantal joint acquired cases when evidence of myelpathy or significant
techniques symptomatic neck pain
halo vest invagination and atlanto-axial impaction secondary to
tongs inflammatory arthropathy (e.g., rheumatoid arthritis)
prolonged cervical orthosis is not tumor
recommended due to poor stabilization of the AOJ
outcomes
use of traction should be avoided in most cases
traction may be considered in stage 2
injuries when MRI demonstates soft-tissue injury with perserved
aligment

Atlas Fracture & hard collar vs. halo immobilization for 6-12 weeks    posterior C1-C2 fusion vs. occipitocervical fusion 
Transverse Ligament indications  indications
Injuries stable Type I fx (intact transverse ligament) unstable Type II (controversial)      
stable Jefferson fx (Type II) (intact transverse unstable Type III  (controversial)
ligament) technique
stable Type III (intact transverse ligament) may consider preoperative traction to reduce displaced
technique lateral masses
controversy exists around optimal form of
immobilization

Odontoid Fracture o observation alone o posterior C1-C2 fusion 

indications indications
Os odontoideum
assuming no neurologic symptoms Type II fractures with risk factors for nonunion 
or instability Type II/III fracture nonunions 
o hard cervical orthosis for 6-12 weeks    Os odontoideum with neurologic deficits or
indications instability
Type I 
 Type II in elderly who are not surgical o anterior odontoid osteosynthesis     
candidates    indications
union is unlikely, however a fibrous Type II fractures with risk factors for nonunion AND
union should provide sufficient stability except in the case of acceptable alignment and minimal
major trauma displacement
Type III fractures      oblique fracture pattern perpendicular to
no evidence to support Halo over screw trajectory
hard collar patient body habitus must allow proper
o halo vest immobilization for 6-12 weeks  screw trajectory
indications outcomes
Type II young patient with no risk factors associated with higher failure rates than posterior
for nonunion C1-2 fusion
contraindications o transoral odontoidectomy
elderly patients indications
do not tolerate halo (may lead to severe posterior displacement of dens with spinal
aspiration, pneumonia, and death) cord compression and neurologic deficits

Traumatic o reduction with surgical stabilization

Spondylolisthesis of o rigid cervical collar x 4-6 weeks   indications
Axis (Hangman's Type II with > 5 mm displacement and
indications
Fracture) severe angulation
Type I fractures (< 3mm horizontal
displacement) Type III (facet dislocations)
o closed reduction followed by halo technique
anterior C2-3 interbody fusion
immobilization for 8-12 weeks
posterior C1-3 fusion
indications
bilateral C2 pars screw osteosynthesis
Type II with 3-5 mm displacement
Type IIA
reduction technique
Type II use axial traction combined
+ extension
 Type IIA use hyperextension
(avoid axial traction in Type IIA)

Cervical Facet o immediate closed reduction, then MRI, then surgical

Dislocations & o cervical orthosis or external stabilization 
Fractures indications 
immobilization (6-12 weeks) 
indications bilateral facet dislocation with deficits
facet fractures without significant in awake and cooperative patient 
subluxation, dislocation, or kyphosis unilateral facet dislocation with deficits
must first rule out instability with flexion- in awake and cooperative patient 
extension radiographs  technique
Operative never perform closed reduction in patient
with mental status changes
surgical stabilization following successful
closed reduction
unilateral dislocations are more
difficult to reduce but more stable after reduction
bilateral dislocation are easier to
reduce (PLL torn) but less stable following reduction
always obtain MRI prior to surgical
stabilization
PSF or ACDF can be
performed in the absence of significant disc herniation
ACDF performed if
significant disc herniation present
outcomes
26% of patients will fail closed reduction
and require open reduction
o immediate MRI then open reduction surgical
stabilization 
indications
facet dislocations (unilateral or bilateral) in
patient with mental status changes 
patients who fail closed reduction
 technique
always obtain MRI prior to open reduction
and stabilization
if disc herniation with presence of
spinal cord compression then you must use an anterior approach and do
a discectomy

Cervical Lateral Mass NSAIDS, rest, immobilization o posterior decompression and two-level instrumented
Fracture Separation indications fusion 
stable injuries without neurological deficit indications
hyperextension/rotation is poorly immobilized in a most cases require surgery
halo main injured structures are posterior, thus
techniques preferred approach is posterior
Miami J collar also indicated for nonoperatively managed cases
halo vest with late instability and persistent pain
outcomes techniques
long term results of non-operative treatment are two-level lateral mass or pedicle screw and rod
less desirable
may be successful in the absence of instability fixation   
surveillance is necessary to detect late instability lateral mass plating   
and persistent pain outcomes
spontaneous fusion rate is only 20% risk of anterior disc space collapse and late
kyphotic deformity
 midline fusion does not control rotation
o two-level ACDF
indications
if mostly reduced and dont need posterior
approach to obtain direct reduction
controls anterior collapse and rotation
techniques
using iliac crest bone graft 
o single posterior pedicle screw   
indications
Type A Separation fracture without instability
o anterior and posterior decompression and fusion
indications
if additional anterior column support is needed
if anterior approach is attempted initially, with
unsuccessful reduction because of complicated fracture morphology or
late presentation

Subaxial Cervical o collar immobilization for 6 to 12 weeks o anterior decompression, corpectomy, strut graft, & fusion
Vertebral Body  indications with instrumentation
Fractures  stable mild compression fractures (intact  indications
posterior ligaments & no significant  compression fracture with 11 degrees of angulation
kyphosis) or 25% loss of vertebral body height
 anterior teardrop avulsion fracture  unstable burst fracture with cord compression
o external halo immobilization  unstable tear-drop fracture with cord compression
 indications  minimal injury to posterior elements
 only if stable fracture pattern (intact  early decompression (< 24 hours) has been shown to
posterior ligaments & no significant improve neurologic outcomes compared with delayed (>/
kyphosis) 24 hours) decompression 
o posterior decompression, & fusion with instrumentation
  indications
 significant injury to posterior elements
 anterior decompression not required

Thoracolumbar Burst o surgical decompression & spinal stabilization
Fractures o ambulation as tolerated with or without a indications
thoracolumbosacral orthosis                    neurologic deficits with radiographic
evidence of cord/thecal sac compression
both complete and incomplete
indications
spinal cord injuries require decompression and stabilization to facilitate
patients that are neurologically
rehabilitation
intact and mechanically stable
posterior ligament complex unstable fracture pattern as defined by 
preserved injury to the Posterior Ligament
kyphosis < Complex (PLC) 
30° (controversial) progressive kyphosis
vertebral body has lost < lamina fractures (controversial)
50% of body height (controversial) TLICS score = 5 or higher 
TLICS score = 3 or lower 
thoracolumbar orthosis 
recent evidence shows no clear
advantage of TLSO on outcomes
if it provides symptomatic
relief, may be beneficial for patient
outcomes
retropulsed fragments resorb over
time and usually do not cause neurologic deterioration

Chance Fracture o surgical decompression and stabilization

(flexion-distraction o immobilization in cast or TLSO indications
injury) indications patients with neurologic deficits
neurologically intact patients with unstable spine with injury to the posterior
stable injury patterns with ligaments (soft-tissue Chance fx)
intact posterior elements techniques
bony Chance fracture anterior decompression and stabilization
 technique usually with vertebrectomy and strut
may cast or brace (TLSO) in grafting followed by instrumentation
extension posterior indirect decompression and
must be followed for non-union stabilization and compression fusion construct
and kyphotic deformity historically three levels above and
two levels below
modern pedicle screws have
changed this to one level above and one level below 
distraction construct in burst
fractures
compression construct in Chance
fractures

Osteoporotic o vertebroplasty   
Vertebral o observation, bracing, and medical indications
Compression management controversial
Fracture indications AAOS recommends strongly against
majority of patients can be treated the use of vertebroplasty in 2011 but then changed their stance in 2014
with observation and gradual return to activity    based on recent studies
PLL intact (even if > 30 degrees outcomes
kyphosis or > 50% loss of vertebral body height)  randomized, double-blind, placebo-
technique controlled trials have shown no beneficial effect of vertebroplasty   
if the fracture is less than five days vertebroplasty has higher rates of cement
old    extravasation and associated complications than kyphoplasty
calcitonin can be used for o kyphoplasty 
four weeks to decrease pain indications
medical management can consist patient continues to have severe pain
of bisphosphonates  symptoms after 6 weeks of nonoperative treatment
to prevent future risk of AAOS recommend may be used, but
fragility fractures recommendation strength is limited
some patients may benefit from technique
an extension orthosis kyphoplasty is different than vertebroplasty
although compliance can in that a cavity is created by balloon expansion and therefore the cement
be an issue can be injected with less pressure
 Operative pain relief thought to be from elimination of
micromotion
o surgical decompression and stabilization
indications
very rare in standard VCF
progressive neurologic deficit
PLL injury and unstable spines
technique
to prevent possible failure due to
osteoporotic bone
consider long constructs with
multiple fixation points
consider combined anterior fixation
o
Adult Pyogenic bracing and long term antibiotic (6-12 weeks)  o neurologic decompression, surgical debridement, and
Vertebral indications spinal stabilization
Osteomyelitis most cases indications
bracing progressive neurologic deficits
helps improve pain and prevent progressive deformity & gross spinal
deformity instability
rigid cervicothoracic orthosis or refractory cases
halo required for cervical osteomyelitis technique
antibiotics dictated by characteristics of pathology
indications anterior debridement and strut
once organism has been grafting, +/- posterior instrumentation
considered to be gold
identified via blood culture or biopsy 
standard
if patient is septic or
posterior debridement and
critically ill then start broad spectrum antibiotics immediately
decompression alone
which include
usually ineffective for
vancomycin
debridement
for
may be indicated in some
pencicillin-resistant and gram-positive bacteria
cases
third-generation
cephalosporin
  for gram-
negative coverage
technique once organism has
been identified
usually treated with IV
culture directed antibiotics until signs of improvement (~ 4-6
weeks) and then converted to PO antibiotics
resistant strains
new antibiotic-resistant
strains of microorganisms are becoming more common and
failure to diagnose can have negative consequences
organisms include
MRSA (methicillin-
resistant Staph aureus)
VRSA (vancomycin
resistant Staph aureus)
VRE (vancomycin
resistant enterococcus)
treatment
newer generation
antibiotics for antibiotic resistant organisms include linezolid and
daptomycin
outcomes
successful in 80%
Operative

Spinal Epidural o surgical decompression +/- spinal stabilization

Abscess o bracing and IV antibiotics  indications
indications neurologic deficits present     
small abscess with minimal evidence of spinal cord compression on
compression on neural elements and imaging studies
no neurologic deficits and persistent infection despite antibiotic
a patient capable of close therapy
clinical followup progressive deformity or gross spinal
those who are not candidates for instability
 surgery due to medical comorbidities postoperative antibiotics
outcomes indicated for 2-4 weeks if no bony
historically presence of epidural involvement of infection
abscess has been considered a surgical emergency indicated for 6 weeks if bony involvement
there has been a recent trend
towards nonoperative management as new studies shows
nonoperative treatment effective in patients without neurologic
deficit
medical treatment failure associated
with:     
neurologic deficits (strongest
predictor of medical treatment failure)
diabetes
CRP >115 mg/L
WBC >12 k/mL
positive blood cultures
age >65 years
MRSA

Spinal Tuberculosis o anterior decompression/corpectomy, strut grafting ±

o pharmacologic treatment +/- spinal orthosis posterior instrumented stabilization ± posterior column
indications shortening   
no neurological deficit indications
drugs are the mainstay of neurologic deficit
treatment in most cases worsening neurological deficit
pharmacologic acute severe paraplegia
agents with panvertebral involvement
isoniazid (H), rifampin (R), with/without subluxation/dislocation
ethambutol (E) and pyrazanamide (Z) therapy spinal instability 
regimen kyphosis correction
RHZE for 2 months, then > 60° in adult 
RH for 9 to 18 months
progressive kyphosis in child 
spinal orthosis
≥3 vertebrae involved with loss of
indications
≥1.5 vertebral bodies in thoracic spine
may be used for pain
control and prevention of deformity children ≤ 7 years with ≥3 vertebral
bodies affected in T/TL spine and ≥ 2 at risk signs are likely to have
progression and should undergo correction
late onset paraplegia (from
kyphosis)
cosmetic correction of
kyphosis controversial
advanced disease
with caseation preventing access by antibiotics
failure of nonoperative treatment after 3 to
6 months
diagnosis uncertain
panvertebral lesion
advantages of surgical treatment
less progressive kyphosis
earlier healing
decreased sinus formation
in patients with neurologic deficits, early
debridement and decompression led to improved neurologic recovery
technical aspects
autogenous and allograft strut grafts are
acceptable with good results
continue medical management
with isoniazid, rifampin, and pyrazanamide
chronic implant colonization is less
common in TB and other granulomatous infections compared to more
common pyogenic infections
o Halo traction, anterior decompression, bone grafting,
anterior plating 
indications
cervical kyphosis 
o Pedicle subtraction osteotomy
indications
lumbar kyphosis
o Direct decompression / internal kyphectomy 
 indications
correction of healed thoracic/thoracolumbar
kyphosis
allows spinal cord to transpose anteriorly
o
o surgical debridement followed by antibiotic treatment
Disk Space Infection o
- bedrest, immobilization, and antibiotics for 4- indications
Pediatric late infection 
6 weeks   
indications paraspinal abscess in the presence of
early infection with no abscess or neurologic deficits
displacement of thecal sac limited responsiveness to nonoperative
modalities measures
initial treatment is with parenteral technique
antibiotics directed at Staph aureus for 7-10 days important to obtain cultures 
followup followed with antibiotics and bracing
watch serial labs to monitor o
efficacy of antibiotic treatment
CRP  is the most sensitive
in monitoring this patient's response to antibiotic therapy 
obtain CT-guided biopsy if no
response (rule out TB)

Spine Surgical Site o urgent surgical debridement, wound management +/-

Infections o oral antibiotics and close observation plastics, ID consult & targeted IV antibiotics
indications indications
only indicated for mild superficial vast majority of cases
infections any infection that does not respond to
antibiotics
unacceptable spinal deformity
neurologic deficits
progression of infection on follow-up MRI
studies
indications for hardware removal
loose hardware
 refractory infections
latent infection and fusion obtained
titianium implants are best for use in
infection cases
indications to retain hardware
 
insufficient stability
lack of solid fusion
outcomes
worse overall long term outcomes
compared to index procedure without infection
increased treatment costs

Cervical Myelopathy o surgical decompression, restoration of lordosis,

o observation, NSAIDs, therapy, and lifestyle stabilization 
modifications indications
indications significant functional impairment AND
mild disease with no functional 1-2 level disease
impairment lordotic, neutral or kyphotic alignment
function is a more techniques
important determinant for surgery than physical exam finding  appropriate procedure depends on
patients who are poor candidates cervical alignment   
for surgery number of stenotic levels
modalities location of compression
medications (NSAIDS, gabapentin) medical conditions (e.g., goiter)
immobilization (hard collar in slight treatment procedures include (see below)
flexion) anterior cervical
physical therapy for neck diskectomy/corpectomy and fusion
strengthening, balance, and gait training posterior laminectomy and
traction and chiropractic modalities
fusion 
are not likely to benefit and do have some risks
posterior laminoplasty
be sure to watch patients carefully
combined anterior and posterior
for progression
outcomes procedure 
improved nonoperative outcomes
 associated with patients with larger transverse area of the spinal cervical disk arthroplasty 
cord (>70mm2)  outcomes
some studies have shown prospective studies show improvement in
improvement with immobilization in patients with very mild overall pain, function, and neurologic symptoms with operative treatment
symptoms
early recognition and treatment prior to
spinal cord damage is critical for good clinical outcomes
goals
prevention of continued neurologic
decline 

Cervical o anterior cervical discectomy and fusion

Radiculopathy o rest, medications, and rehabilitation  indications
indications persistent and disabling pain that has failed
75% of patients with radiculopathy nonoperative modalities
progressive and significant neurologic
improve with nonoperative management        deficits
improvement via resorption of soft outcomes
discs and decreased inflammation around irritated nerve roots remains gold standard in surgical treatment
techniques (very few substantiated by of cervical radiculopathy
evidence) single level ACDF is not a contraindication
immobilization for return to play for athletes
immobilization for short o posterior foraminotomy 
period of time (< 1-2 weeks) may help by decreasing
inflammation and muscles spasm indications 
medications foraminal soft disc herniation causing single
NSAIDS / COX-2 inhibitors level radiculopathy ideal
oral corticosteroids may be used in osteophytic foraminal
GABA inhibitors (neurontin) narrowing
narcotics outcomes
muscle relaxants 91% success rate
rehabilitation reduces the risk of iatrogenic injury with
moist heat anterior approaches
o
cervical isometric exercises cervical total disc replacement
traction/manipulation indications (controversial)
 avoid in single level disease with minimal arthrosis
myelopathic patients of the facets 
return to play  outcomes
indicated after resolution of studies show equivalence to ACDF
symptoms and repeat MRI demonstrating no cord compression effect on adjacent level disease remains
studies have shown return to play unclear
expedited with brief course of oral methylprednisolone (medrol some studies show 3% per year for
dose pack)  all approaches
no increased risk of subsequent
spinal cord injury
o selective nerve root corticosteroid injections 
indications
may be considered as therapeutic
or diagnostic option
outcomes
Provides long-term relief in 40-
70% of cases 
increased risk when compared to
lumbar selective nerve root injections with the following rare but
possible complications, including
dural puncture
meningitis
epidural abscess
nerve root injury

Atlantoaxial o posterior C1-C2 fusion

Subluxation indicated in stable atlantoaxial subluxation general indications for surgery
o AADI > 10 mm (even if no neuro deficits)
SAC / PADI < 14 mm (even if no neuro
deficits)
progressive myelopathy
indications for posterior C1-2 fusion
able to reduce C1 to C2 so no need to
remove posterior arch of C1
 technique
adding transarticular screws eliminated
need for halo immobilization (obtain preoperative CT to identify location
of vertebral arteries)
occiput-C2 fusion ± resection of posterior C1 arch
indications
when atlantoaxial subluxation is combined
with basilar invagination
resection of C1 posterior arch for complete
decompression
leads to indirect decompression of
anterior cord compression by pannus
may be required if atlantoaxial
subluxation is not reducible 
odontoidectomy
indications
rarely indicated
used as a secondary procedure when there
is residual anterior cord compression due to pannus formation that fails to
resolve with time following a posterior spinal fusion
pannus often resolves following
posterior fusion alone due to decrease in instability

Atlantoaxial o o C2 to occiput fusion

Subluxation  indications
 progressive cranial migration (> 5 mm) 
 neurologic compromise
 cervicomedullary angle <135° on MRI
o transoral or anterior retropharyngeal odontoid resection 
 indications
 brain stem compromise

Subaxial subluxation o
posterior fusion and wiring
indications
 > 4mm / >20% subaxial subluxation + intractable pain and
neurologic symptoms

Cervical Adjacent  extension of fusion construct to affected levels

Segment Disease  oral medications, activity  indications
modifications, physical therapy, +/- brief o clinical radiculopathy consistent with the
period of immobilization adjacent segment that have not responded
 indications well to nonoperative treatment
o first line of treatment for o myelopathy 
radiculopathy and mild myelopathy  inclusion of C5-6 and/or C6-7 into the fusion
without impairment construct 
 modalities o highest liklihood of developing ASD
o oral medications  place anterior plate >5 mm from the adjacent level 
o NSAIDs o reduces the risk of adjacent level
o use caution in ossification
elderly patients due  including >3 levels has a reduced risk of
to risk of gastric developing further ASD
bleeding  cervical total disc replacement 
o gabapentin  indications
o commonly used for o single level involvement
nerve and  as an index procedure does not appear to have an
associated pain protective effect on ASD
o narcotics o large meta-analyses suggest possible
o should be avoided decrease in reoperation rates 
for any chronic  for the treatment of ASD appears equivalent to
condition ACDF
o brief period of immobilization  reduced risk of adjacent segment ossification
o some studies show it is compared to anterior cervical plating
beneficial
 severe myelopathy should be surgically
addressed to avoid stepwise deterioration 

Discogenic Back Pain o lumbar diskectomy with fusion

o NSAIDS, physical therapy, cognitive therapy, lifestyle indications
 modifications controversial
indications outcomes
treatment of choice of majority of poor results when lumbar fusion is
patients with low back pain in the abscence of leg pain performed for discogenic back pain diagnosed with a positive provocative
outcomes discography 
no statisically significant o lumbar total disc replacement   
difference in ODI at short (1 year) or long term (10 years) for indications  
patients treated with cognitive and exercise therapy compared to controversial
lumbar diskectomy with fusion  most argue single level disc
disease with disease-free facet joints is the only true indication
outcomes
shown to have better 2-year patient
outcomes than fusion
lower rates of adjacent segment disease
with total disc replacement compared to fusion
complications
persistent back pain
thought to be facet joint in origin or
subtle instability of prosthesis
if implant in good position, treat with
posterior stabilization alone
dislocation of polyethylene inlay 
treat with either revision arthroplasty
or revision to arthrodesis

Thoracic Disc   Operative

Herniation o activity modification, physical therapy, and symptomatic o discectomy with possible hemicorpectomy or fusion 
treatment   indications
 indications  surgery indicated in minority of patients
 the majority of cases  acute disc herniation with myelopathic
 modalities include findings attributable to the lesion, especially
 immobilization and short term rest if there is progressive neurologic
 analgesic deterioration 
 progressive activity restoration  persistent and intolerable pain
  injections may be useful for  technique
symptoms of radiculopathy  debate between discectomy with or without
 outcomes fusion is controversial.
 majority improve with nonoperative  most studies do indicate that
treatment  anterior or lateral (via
 costotransversectomy) is the best
approach 
 see below for different approaches 
o
Lumbar Disc  rest and physical therapy, and antiinflammatory  laminotomy and discectomy (microdiscectomy)   
Herniation medications    o indications       
o indications  persistent disabling pain lasting more than 6 weeks
 first line of treatment for most patients with that have failed nonoperative options (and epidural
disc herniation injections) 
 90% improve without surgery  progressive and significant weakness
o technique  cauda equina syndrome
 bedrest followed by progressive activity as o technique
tolerated  can be done with small incision or through "tube"
 medications access
 NSAIDS o rehabilitation
 muscle relaxants (more effective  patients may return to medium to high-intensity
than placebo but have side effects)
 oral steroid taper activity at 4 to 6 weeks 
 physical therapy o outcomes
 extension exercises extremely  outcomes with surgery compared to nonoperative
beneficial  improvement in pain and function greater
 traction with surgery   
 chiropractic manipulation  positive predictors for good outcome with surgery
 selective nerve root corticosteroid injections   leg pain is chief complaint 
o indications  positive straight leg raise
 second line of treatment if therapy and  weakness that correlates with nerve root
medications fail impingement seen on MRI
o technique  married status
  epidural  professional athletes 
 selective nerve block  younger age, greater number of
o outcomes games played prior to injury
 leads to long lasting improvement in ~  negative predictors for good outcome with surgery
50% (compared to ~90% with surgery)
 worker's compensation   
 results best in patients with extruded
 WC patients have less relief from
discs as opposed to contained discs
symptoms and less improvement in

quality of life with surgical
treatment 
 far lateral microdiskectomy 
o indications
 for far-lateral disc herniations 
o technique
 utilizes a paraspinal approach of Wiltse
o
Cauda Equina
Syndrome urgent surgical decompression within 48 hours 
 indications
o significant suspicion for CES
o severity of symptoms will increase the urgency of surgical
decompression
 techniques
o diskectomy 
o laminectomy
 outcomes
o studies have shown improved outcomes in bowel and bladder
function and resolution of motor and sensory deficits when
decompression performed within 48 hours of the onset of symptoms
o
Lumbar Spinal  o wide pedicle-to-pedicle decompression      
Stenosis o oral medications, physical therapy, and corticosteroid  indications
injections  persistent pain for 3-6 months that has
  indications failed to improve with nonoperative
 first line of treatment management
o modalities include  progressive neurologic deficits (weakness
 NSAIDS, physical therapy, weight loss or bowel/bladder)
and bracing o wide pedicle-to-pedicle decompression with instrumented fusion
 steroid injections (epidural and  indications
transforaminal)   segmental instability (isthmic
 found to be effective and may spondylolisthesis, degenerative
obviate the need for surgery spondylolisthesis, degenerative scoliosis)
 surgical instability 
 created by complete laminectomy
and/or removal of > 50% of
facets   
 risk of adjacent segment degeneration
>30% at 10 years
o
Synovial Facet Cyst  NSAIDS, rest, immobilization, physical therapy,  laminectomy with decompression and cyst excision   
epidural steroid injections o indications
o indications  persistent symptoms despite non-operative
 mild symptoms management
 first-line treatment  unilateral symptoms
 radicular pain without motor weakness  can be performed in patients with
o outcomes spondylolisthesis with unilateral symptoms
 no natural history studies have been as long as they are aware of the higher risk
conducted to date of slip progression
 CT-guided cyst rupture, facet steroid injection, cyst o outcomes   
injection 
 high incidence of recurrent back pain and cyst
o indications
formation within two years
 second-line management after failing  80-90% success rate in back and leg pain 
conservative measures  risk of iatrogenic spondylolisthesis
 radicular symptoms correlate with facet
cyst location  facetectomy and instrumented fusion   
o outcomes o indications
 50-75% pain relief at 1-year  some consider first line of surgical treatment due to
  approximately 39% of patients will require high recurrance rates
surgical intervention at 7 months  symptomatic recurrence following laminectomy
 with decompression 
 bilateral symptoms 
 central canal stenosis
 wider decompression will likely lead to
iatrogenic instability
 presence of instability (e.g. degenerative
spondylolisthesis)
o outcomes
 demonstrated to have the lowest risk of persistent
back pain and recurrence of cyst formation in
recent studies
 complete resolution of symptoms in 80-90% of
patients
o
Degenerative  physical therapy and NSAIDS o lumbar wide decompression with instrumented fusion     
Spondylolisthesis o indications
       
 most patients can be treated
indications
nonoperatively
most common is persistent and incapacitating pain
o modalities include
that has failed 6 mos. of nonoperative management and epidural steroid
 activity restriction
injections
 NSAIDS
progressive motor deficit
 PT
cauda equina syndrome
 epidural steroid injections outcomes 
o indications ~79% have satisfactory outcomes
 second line of treatment if non-invasive improved fusion rates shown with pedicle screws
methods fail
 improved outcomes with successful arthrodesis 
worse outcomes found in smokers 
o posterior lumbar decompression alone 
indications
usually not indicated due to instability associated
with spondylolithesis
 only indicated in medically frail patients who cannot
tolerate the increased surgical time of performing a fusion
outcomes
~69% treated with decompression alone are
satisfied
~ 31% have progressive instability
o anterior lumbar interbody fusion (ALIF)
indications
reserved for revision cases with pseudoarthrosis
outcomes
injury to superior hypogastric plexus can cause
retrograde ejaculation 
o
Adult Isthmic oral medications, lifestyle modifications, therapy   L5-S1 decompression and instrumented fusion +/- reduction
Spondylolisthesis  indications o indications
o most patients can be treated nonoperatively  L5-S1 low-grade spondylolisthesis with persistent
 techniques and incapacitating pain that has failed 6 months of
o activity restriction nonoperative management (most common)
 progressive neurologic deficit
o NSAID
 slip progression
o role of injections unclear
 cauda equina syndrome
o bracing may be beneficial especially in the acute phase o reduction
  improved sagittal balance with reduction
 risk of stretch injury to L5 nerve root with
reduction 
 L4-S1 decompression and instrumented fusion +/-
reduction 
o indications
 L5-S1 high-grade spondylolithesis with persistent
and incapacitating pain that has failed 6 months of
nonoperative management
 ALIF
o indications
  can be used successfully to treat low-grade isthmic
spondylolisthesis even when radicular symptoms
are present
 cannot be used to treat high grade isthmic
spondylolisthesis due to translational and angular
deformity
o outcomes
 studies have shown good to excellent results in 87-
94% at 2 years
o
Adult Spinal observation with nonoperative modalities  surgical curve correction with instrumented fusion
Deformity  indications  general indications
o coronal curves < 30 degrees rarely progress o curve > 50 degrees of the following type
 modalities o sagittal imbalance
o oral medications o curve progression
 NSAIDS o intractable back pain or radicular pain that has failed nonsurgical
 tricyclic antidepressants help with sleep efforts
disturbance o cosmesis (controversial)
o physical therapy  o cardiopulmonary decline
 includes core strengthening (walking,  thoracic curves >60deg affect pulmonary function
cycling, swimming, selected weight lifting) tests
o corticosteroid injections and nerve root blocks  thoracic curves >90deg affect mortality
 diagnostic and therapeutic  technique
o bracing o posterior only curve correction and instrumented fusion
 may slow progression and increase  indications
comfort  thoracic curves > 50 degrees
  most double structural curves > 50 degrees
 selecting technique is patient and surgeon
specific
o combined anterior/posterior curve correction with instrumented fusion
 indications
 isolated thoracolumbar
 isolated lumbar curves
 extremely rigid curves requiring anterior
 release
o
Sacroiliac Pain and  Oral medication, physical therapy (+/- hot/cold  Open SI joint arthrodesis
Dysfunction therapy), pelvic belt, and prolotherapy o indications
o indications  confirmed diagnosis of SI joint dysfunction as
 first line of treatment primary pain generator
o outcomes  poor response to nonoperative treatment options
 most effective in the acute phase of pain  patients with aberrant SI anatomy, sacral
 pelvic belt more effective for SI joint pain dysmorphism, or revision surgery
following pregnancy  previously infection was the only indication for
 prolotherapy more effective in the setting arthrodesis
of ligamentous laxity o outcomes
 SI joint injections  new literature with favorable outcomes in
o indications appropriately selected patients
 second line of treatment  Minimally Invasive SI joint arthrodesis
o outcomes o indications
 60% success rate in pain relief at 6  confirmed diagnosis of SI joint dysfunction as
months primary pain generator
 >75% reduction in SI joint  poor response to nonoperative treatment
pain following a single injection is  normal SI joint anatomy
confirmatory of the diagnosis   no presence of infection
 >50% reduction in SI joint pain o outcomes
following two injections  shorter hospital stay
 lower success rate in patients with  smaller incision
previous lumbar fusion   theoretical decrease in surgical site infections
 radiofrequency ablation of the lateral branches of the  decreased limitation of postoperative
sacral nerve roots weightbearing
o indications  quicker return to full weightbearing than
open arthrodesis
 third line of treatment
 decreased blood loss 
o outcomes
o
 efficacy is limited due to the inability to
denervate the anterior neural structues of
the SI joint

Pediatric par interarticularis repair 
Spondylolisthesis & observation with no activity limitations  indications
Spondylolysis indications  L1 to L4 isthmic defect that has failed
asymptomatic patients with low-grade spondylolisthesis or spondylolysis
nonoperative management
may participate in contact sports   multiple pars defects
o L5-S1 in-situ posterolateral fusion with bone grafting
physical therapy and activity restriction 
 indications
indications
 L5 spondylolysis that has failed
symptomatic isthmic spondylolysis
nonoperative treatment
symptomatic low grade spondylolisthesis
 low grade spondylolisthesis (Myerding
technique
Grade I and II) that
physical therapy should be done for 6 months and include
 has failed nonoperative treatment
hamstring stretching
 is progressive
pelvic tilts
 has neurologic deficits
 abdominal strengthening 
 is dysplastic due to high propensity
watch low grade dysplastic carefully 
for progression
TLSO bracing for 6 to 12 weeks  o L4-S1 posterolateral fusion, +/- reduction,  (+/- ALIF)
indications  indications
acute pars stress reaction spondylolysis  high grade isthmic spondlylisthesis
isthmic spondylolysis that has failed to improve with physical therapy
(Meyerding Grade III, IV, V) 
low grade spondylolisthesis that has failed to improve with physical therapy
o reduction is extremely controversial with no accepted guidelines 
outcomes
brace immobilization is superior to activity restriction alone for acute stress reaction spondylolysis
Operative

  o posterior C1-C2 fusion   

 15 o soft collar, NSAIDS, exercise program  indications
Atlantoaxial Rotatory  indications   subluxation persists > 3 mos 
Displacement (AARD)  subluxation present for < 1  neurologic deficits present
week (traumatic or Grisel's  failed halo traction x 2 weeks
disease)   recurrent subluxation
 many patients probably reduce o
spontaneously before seeking
 medical attention
o head halter traction, NSAIDS, benzodiazepines, then
hard collar x 3 months
 indications
 subluxation persists > 1 week
 persistent torticollis in spite of soft
collar (above) x 2 weeks
 technique
 small amount (5 lbs.) usually
enough
 either in hospital or at home
 muscle relaxants and analgesics
may be needed
o halo traction, then halo vest x 3 months 
 indications
 subluxation persists > 1 mos.
 failed halter traction x 2 weeks
(above)

Congenital Muscular  o bipolar release of SCM or Z plastic lengthening

Torticollis o passive stretching  indications
 indications  failed response to at least 1 year of
 condition present for less than 1 stretching
year  Significant deformity
 limitation less than 30°  good results reported even in older children (4-8
 stretching technique years)
 should include lateral head tilt  Post-op:Consider immobilization in over corrected
away from the affected side and position
chin rotation toward the affected o
side (opposite of the deformity) 
 outcomes
 90% respond to passive
stretching of the
sternocleidomastoid in the first
 year of life
 associated plagiocephaly does
remodel and improve, but this
process is delayed in older
children

Klippel-Feil Syndrome  o surgical decompression and fusion

o observation, OK to participate in contact/ collision  indications
sports  basilar invagination
 indications  chronic pain
 asymptomatic patients with fusions  myelopathy
of 1-2 disc spaces below C3  associated atlantoaxial instability
o observation, abstain from contact / collision sports  adjacent level disease if symptomatic
 indications o
 asymptomatic patients with fusion
involving C2
 most common presentation
 long fusions
o modalities
 counseling important to avoid activities
that place the neck at high risk of
injury 
 contact sports, gymnastics,
football, wrestling, trampoline, etc

Adolescent Idiopathic o posterior spinal fusion

Scoliosis o observation alone  indications
 indications   cobb angle > 45°   
 cobb angle < 25°  can be used for all types of idiopathic
 technique scoliosis
 obtain serial radiographs to  remains gold standard for thoracic and
monitor for progression double major curves (most cases)
o bracing    o anterior spinal fusion
 indication   indications
  cobb angle from 25° to 45°  best for thoracolumbar and lumbar cases
 only effective for flexible deformity with a normal sagittal profile
in skeletally immature patient o anterior / posterior spinal fusion
(Risser 0, 1, 2)  indications
 goal is to stop progression, not to  larges curves (> 75°) or stiff curves
correct deformity  young age (Risser grade 0, girls <10 yrs,
 outcomes boys < 13 yrs)
 50% reduction in need for surgery  in order to prevent crankshaft
with compliant brace wear of at phenomenon 
least 13 hours a day  o
 poor prognosis with brace
treatment associated with
 poor in-brace correction
 hypokyphosis (relative
contraindication)
 male
 obese
 noncompliant
(effectiveness is dose
related)
 Sanders staging system 
 predicts the risk of curve
progression despite bracing
to >50 degrees in Lenke
type I and III curves
 uses anteroposterior hand
radiograph and curve
magnitude to assess risk of
progression despite bracing

Juvenile Idiopathic o non-fusion procedures (growing rods, VEPTR) 

Scoliosis o observation indications
indications curves > 50° in small children with
curves < 20° significant growth remaining
 technique allows continued spinal growth over
frequent radiographs to observe unfused segments
for curve progression definitive PSF + ASF performed
o bracing when the child has grown and is closer skeletal maturity
indications o anterior / posterior spinal fusion
curves 20 - 50° indications
designed to prevent curve curves > 50° in younger patients
progression, not correct the curve required in order to prevent crankshaft
relative contraindication to bracing phenomenon
is thoracic hypokyphosis o posterior spinal fusion
technique indications
16-23h/day until skeletal growth curve > 50° in older patients near skeletal
completed or surgery indicated maturity   
remains gold standard for thoracic and
double major curves (most cases)
o anterior spinal fusion
indications
curve > 50°
best for thoracolumbar and lumbar cases
with a normal sagittal profile
o
Infantile Idiopathic  o growing rod construct (dual rod or VEPTR)
Scoliosis o observation alone (most resolve spontaneously)  indications
 indications  Cobb > 50 to 60 degrees
 Cobb angle < 30°  failed Mehta casting or bracing
 RVAD < 20°  fusion
 90% will resolve spontaneously  delay until as close to skeletal maturity as
o serial Mehta casting (derotational) or possible
 fusion before age 10 years results in
thoracolumbosacral orthosis (TLSO)     
pulmonary compromise
 indications
o
 flexible curves
 Cobb angle > 30°
 RVAD > 20°
 phase 2 rib-vertebrae relationship
 (rib-vertebral overlap)
 mechanism
 functions to straighten the spine in
young patients
 in older patients it serves as an
adjunctive measure prior to
definitive treatment
o bracing
 indications
 incompletely corrected curves after
Mehta casting
 late presenting cases where the
spine is still flexible

Congenital Scoliosis  o posterior fusion (+/- osteotomies and modest correction)

o observation and bracing  indications
 indications for observation  hemi-vertebrae opposite a unlateral bar that
 absence of documented does not require a vertebrectomy at any
progression, ie: age.  this otherwise will relentlessly
 incarcerated hemivertebrae progress until fused.
 nonsegmental  older patients with significant progression,
hemivertebrae neurologic deficits, or declining respiratory
 some partially segmented function
hemivertebrae  having many pedicle screws may decrease
 bracing crankshaft phenomenon adn obviate the
 not indicated in primary treatment need for an anterior fusion.
of congenital scoliosis (no o anterior/posterior spinal fusion +/- vertebrectomy
effectiveness shown)  indications
 may be used to control supple  young patients with significant progression,
compensatory curves, but neurologic deficits, or declining respiratory
effectiveness is unproven function
 girls < 10 yrs
 boys < 12 yrs
 patients with failure of formation with
contralateral failure of segmentation at any
 age that requires hemi-vertebrectomy
and/or significant correction. This may be
done from a posterior approach 
 technique
 nutritional status of patient must be
optimized prior to surgery
o distraction based growing rod construct
 indications
 may be used in an attempt to control
deformity during spinal growth and delay
arthrodesis
 outcomes
 need to be lengthened approximately every
6 months for best results
o osteotomies between ribs 
 indications
 mulitple (>4) fused ribs wit potential for
thoracic insufficiency syndrome
 outcomes
 long-term follow up is needed to determine
efficacy. the downside is this may make the
chest stiff and hurt pulmonary function.
o Hemi-Vertebrectomy - usally done from a posterior approach,
particularly with kyphosis. 
 indications - age 3-8 years (younger is difficult to
get good anchor purchase)
 progressive or significant deformity 
o
Cerebral Palsy -  o PSF with/without extension to the pelvis 
Spinal Disorders o observation, custom seat and/or bracing, botox  indications
injections  Group I curves 50° to 90° in ambulators
 indications that is progressive or interfering with sitting
 nonprogressive curves < 50° position
 early stages in patients < 10 years
 of age  patient > 10 yrs of age
 goal is to delay surgery  adequate hip range of motion
until an older age  stable nutritional and medical status
 outcomes  indications to extend to pelvis
 custom seat orthosis  pelvic obliquity > 15°
 helpful with seating but  required due to increased
does not affect natural pseudoarthosis rate if you do not do
course of disease it
 bracing  technique
 TLSO is helpful to improve  treated as idiopathic scoliosis with selective
sitting balance but does not fusion
affect natural course of  can result in worsening pelvic obliquity and
disease sitting imbalance
 some studies have o PSF +/- ASF with/without extension to pelvis
supported use as a  indicated for
palliative measure to slow  Group I curves >90° and in non-
progression in skeletally ambulators 
immature patients only  Group II curves 
 botox  children who have not yet reached skeletal
 competitive inhibitor of maturity (avoid crankshaft phenomenon)
presynaptic cholinergic o growing rod distraction
receptor with a finite
 indications
lifetime (usually last 2-3
 young patient age
months)
 technique
 provide some short term
 may be magnetic or conventional growing
benefit in patients with
rod
spinal deformity
o

Scheuermann's  o posterior spinal fusion ± osteotomy ± anterior release

Kyphosis o stretching, observation, physical therapy  indications
 indications  kyphosis > 75 degrees 
 kyphosis < 60° and asymptomatic  neurologic deficit
(mild symptoms)  spinal cord compression
 most patients fall in this  severe pain in adults
 group and can be treated  techniques
with observation alone  Smith-Petersen osteotomy
 modalities  best for long sweeping, global
 physical therapy kyphosis
 postural improvement  less than the typical 10° sagittal
exercises and back plane correction per level given
extensor strengthening ridigity 
 core muscle strengthening  anterior release 
for patients with  technique of the past, rarely done
spondylolysis now due to pedicle screw
 limited effectiveness  constructs 
o bracing with an extension-type orthosis (Jewitt type - with  fusion
high chest pad)  dual rod instrumentation usually
 indications performed
 kyphosis 60°-80° most effective in  outcomes
those with growth remaining  studies show 60-90% improvement of pain
 outcomes with surgery (no correlation with amount of
 patient compliance is often an correction)
issue  studies suggest residual curves >75° lead
 most favorable in curves <65°, to worse functional outcomes
correction of >15° in brace o
 usually does not lead to correction
but can stop progression

Os Acromiale  o two-stage fusion
o observation, NSAIDS, therapy, subacromial  indications
corticosteroid injections  symptomatic os acromiale with
 indications impingement
 mild symptoms  technique
  direct excision can lead to deltoid
dysfunction
 a two-stage procedure may be required
 first stage - fuse the os acromiale ±
bone graft
 second stage -
 perform acromioplasty
 preserve blood supply (acromiale branch of
thoracoacromial artery)
 tension band wires, sutures, cannulated
screws
o arthroscopic subacromial decompression and acromioplasty
 indications
 impingement with/without rotator cuff tear
(where the os acromiale is only incidental
and nontender)
o open or arthroscopic fragment excision
 indications
 symptomatic pre-acromion with small
fragment
 salvage after failed ORIF
 results
 arthroscopic has less periosteal and deltoid
detachment
 better excision results with pre-acromion
o
Subacromial  o subacromial decompression / acromioplasty  
Impingement o physical therapy, oral anti-inflammatory  indications
medication, subacromial injections   subacromial impingement syndrome that
 indications has failed a minimum of 4-6 months of
 first line and mainstay of treatment nonoperative treatment
of subacromial impingement alone  outcomes
without rotator cuff tear  poor subjective outcomes have been
 techniques observed after acromioplasty in patients
 aggressive rotator cuff with 
strengthening and periscapular  workers' compensation claims    
stabilizing exercises  anxiety and depression
 an integrated rehabilitation o
program is indicated in the
presence of scapular dyskinesia
 which aims to regain full shoulder
range of motion and coordinate the
scapula with trunk and hip motions
 platelet-rich plasma injections
 most recent meta-analysis
showing insufficient
evidence to support use

Subcoracoid  o arthroscopic coracoplasty ± subscapularis repair   

Impingement o rest, ice, activity modification, NSAIDS, corticosteroid  indications
injections  symptoms refractory to conservative
 indications treatment 
 first line of treatment  subscapularis tearing secondary to
 techniques impingement
 local corticosteroid injections can  technique 
be diagnostic and therapeutic  resect posterolateral coracoid to create 7
 PT focuses on stretching mm clearance between coracoid and
 subscapularis
 if significant subscapularis tendon tear then
repair 
o open coracoplasty
 indications
 symptoms refractory to conservative
treatment 
 subscapularis tearing secondary to
impingement
 technique
 resect lateral aspect of coracoid process
and reattach the conjoined tendon to the
remaining coracoid
o
Calcific Tendonitis  o surgical decompression of calcium deposit 
o NSAIDs, physical therapy, stretching & strengthening,  indications
steroid injections  progression of symptoms
  indications  refractory to nonoperative treatments
 first line of treatment for all  interference with activities of daily living
phases   outcome
 techniques  good results in short term outcome studies
 steroid injections  longer return to work with subacromial
 commonly used but decompression and/or rotator cuff repair
controversial  risk of shoulder stiffness with operative
 duration of relief is variable treatment
 outcomes o
 resolution of symptoms in 60-70%
of patients after 6 months
 increased probability of failure
when:
 bilateral or large
calcifications
 deposits underlying the
anterior third of acromion
 deposits extending medial
to the acromion
o extracorporeal shock-wave therapy
 indications 
 adjunct treatment 
 most useful in refractory calcific
tendonitis in the formative and
resting phases
 modalities
 high- vs. low-energy therapy
 outcomes
 dose dependent outcomes
 high-energy > low-energy
in clinical outcome scores,
and rate of calcific deposit
resorption
 high-energy > low-energy
in procedural pain and local
 reaction (e.g. ecchymosis)
o ultrasound-guided needle lavage vs. needle barbotage
 indications
 persistent symptomatic calcific
tendonitis in the resorptive phase
 outcomes
 improved outcomes in patients
with Type II/III calcific tendinitis vs
Type I

Rotator Cuff Tears  o subacromial decompression and rotator cuff debridement alone
o physical therapy, NSAIDS, subacromial corticosteroid  indications
injections     select patients with a low-grade partial
 indications articular sided rotator cuff tear 
 first line of treatment for most tears o rotator cuff repair (arthroscopic or mini-open)         
 partial tears often can be managed  indications
with therapy
 technique  acute full-thickness tears 
 avoidance of overhead activities  bursal-sided tears >3 mm (>25%) in
 physical therapy with aggressive depth     
rotator cuff and scapular-stabilizer  release remaining tendon and
strengthening over  a 3-6 month debride degenerative tissue
treatment course  partial articular-side tears>50% can be
 subacromial injections if treated with tear completion and repair   
impingement thought to be major  Partial articular-side tears <50%
cause of symptoms treated with debridement alone
  PASTA with >7mm of exposed bony
footprint between the articular surface and
intact tendon represents significant (>50%)
cuff tear (must have at least 25% healthy
bursal sided tissue)
 younger patients with acute,
traumatic tears 
 in situ repair leave bursal
 sided tissue intact 
 older patients with degenerative
tears
 tendon release, debridement
of degenerative tissue and
repair
 postoperative
 rate-limiting step for recovery is biologic
healing of RTC tendon to greater
tuberosity, which is believed to take 8-12
weeks
 peribursal tissue and holes drilled in
greater tuberosity are major source
of vascularity to repaired rotator
cuff 
 vascularity can increase with
exercise
 postop with limited passive ROM (no active
ROM)
 outcomes
 Worker's Compensation patients report
worse outcomes
 higher postop disability and lower
patient satisfaction 
o tendon transfer
 indications
 massive cuff tears
 techniques (see details below)
 pectoralis major transfer
 latissimus dorsi transfer
 best for irreparable posterosuperior
tears with intact subscapularis   
   
o reverse total shoulder arthroplasty
  indications
 massive cuff tears with glenohumeral
arthritis with intact deltoid
o
Rotator Cuff  o arthroscopic debridement
Arthropathy o activity modification, subacromial steroid injection,  indications
physical therapy  controversial
 indications  outcomes
 first line of treatment  unpredictable results
 technique  must maintain coracoacromial arch without
 physical therapy with a scapular acromioplasty or release of CA ligament
and rotator cuff strengthening o hemiarthroplasty     
program  indications
 non-steroidal anti-inflammatories  anterior deltoid is preserved
 subacromial steroid injections  coracoacromial arch intact
 deficiency of the coracoacromial
arch will lead to subcutaneous
humeral escape
 younger patients with active lifestyles
 outcomes
 will relieve pain but will not improve function
(motion limited to 40-70 degrees of
elevation)
o reverse shoulder arthroplasty 
 indications
 pseudoparalytic cuff tear arthropathy
 preferred in elderly (>70) with low activity
level
 anterosuperior escape
 requires functioning deltoid (axillary nerve)
and good bone stock
 deltoid is used to assist
glenohumeral joint to act like a
fulcrum in elevation
  outcomes (short and intermediate at this point)
 has the potential to improve both function
and pain
 risk of inferior scapular notching with poor
technique
o latissimus dorsi transfer
 indications
 pseudoparesis with external rotation     

 combination with reverse total shoulder

arthroplasty
o pectoralis transfer
 indications
 internal rotation deficiency and
subscapularis insufficiency
 techniques
 upper portion or whole pectoralis tendon
transferred near subscapularis insertion on
lesser tuberosity
 complications
 musculocutaneous nerve injury 
o resection arthroplasty
 indications
 salvage only (chronic osteomyelitis,
infections, poor soft tissue coverage)
o glenoid resurfacing
 contraindicated
 excess shear stress on superior glenoid
leads to failure through loosening
o TSA
 contraindicated
o
Biceps Tendonitis  o arthroscopic tenodesis vs. tenotomy
o NSAIDS, PT strengthening, and steroid injections  indications 
  indications  surgical release reserved for refractory
 first line of treatment cases for bicep pathology seen during
 technique arthroscopy 
  direct steroid injection in
proximity, but not into tendon  technique 
 repair vs. release/tenodesis 
 post-op rehab: tenodesis  
 avoid active forearm supination with the
elbow at 90° of flexion 
 outcomes
 tenotomy may be associated with arm
cramping and cosmetic deformity ("Popeye
deformity")
 tenodesis may be associated with "groove
pain" 
 no difference in strength between two
techniques - both recover elbow and
forearm strength post-op 
o
Acromioclavicular  o CC interval restoration (ORIF vs. Ligament Reconstruction)
Joint Injury o brief sling immobilization, rest, ice, physical therapy   indications
 indications  acute type IV, V or VI injuries
 type I and II   recent studies suggest no difference
 type III in most individuals in functional outcomes between
 good results when clavicle operative and nonoperative
displaced < 2cm interventions for high grade injuries
 rehab  acute type III injuries in laborers, elite
 early shoulder range of motion athletes, patients with cosmetic concerns
 regain functional motion by 6  chronic type III injuries that failed non-op
weeks treatment
 return to normal activity at 12  historically it was thought acute
weeks injuries were treated with ORIF and
 consider corticosteroid injections chronic injuries were treated with
CC ligment reconstruction
 outcomes 
  type III treated non-op had higher  however, new studies have
DASH scores at 6 weeks and 3 shown no difference in
months, and equal function at 1 outcomes in types III injuries
year with lower rate of secondary treated surgically after 6
surgery (removal of hardware) weeks non-op treatment
compared to those treated versus immediate surgery
operatively  contraindications
 complications  patient unlikely to comply with
 AC joint arthritis postoperative rehabilitation
 chronic subluxation and instability  skin problems over fixation approach site
 techniques
 ligament reconstruction with soft tissue
graft
 Modified Weaver-Dunn
 distal clavicle excision with
transfer of coracoacromial
ligament to the distal clavicle
to recreate CC ligament
 autograft
 allograft
 fixation
 suture
 hook plate
 CC screw (Bosworth)
 cortical flip button (e.g Dog Bone)
(+/- arthroscopic assistance)
 K-wire 
 rehabilitation
 sling immobilization for 6 weeks, no
shoulder range of motion
 return to full activity after 6 months 
o
Distal Clavicle  o open or arthroscopic distal clavicle excision     
Osteolysis o activity modification, NSAIDs  indications
 indications
  first line of treatment  persistent symptoms that have failed
 modification nonoperative treatment
 avoid aggravating weight-lifting  technique
exercises or modify technique  need to address associated pathology to
 ie. moving hand grip closer the rotator cuff and long head of biceps
together and ending weight  outcomes
descent to 4 to 6 cm above  open vs. arthroscopic based on surgeon
the chest preference and comfort
o corticosteroid injections  arthroscopic resection has the
 indications advantage of allowing evaluation of
 diagnostic and therapeutic the glenohumeral joint
 technique  good results are shown with
 more accurate with ultrasound arthroscopic treatment 
 quicker recovery and return
to activity
 open procedures require meticulous
repair of deltoid-trapezial fascia
o
AC Arthritis  o arthroscopic vs. open distal clavicle resection (Mumford
o activity modification and physical therapy procedure) 
 first line of treatment  indications
 avoid aggravating activity such as  severe symptoms that have failed
pushing/pressing activities nonoperative treatment
 physical therapy should focus on  outcomes
strengthening and stretching of shoulder  open vs. arthroscopic based on surgeon
girdle preference and comfort
o AC joint injection with corticosteriods   arthroscopic resection has the
 can be both diagnostic and advantage of allowing evaluation of
therapeutic modality the glenohumeral joint and
 access to the AC joint is challenging treatment of any associated injuries
 AC joint injections often miss the joint (otator cuff, long head of biceps and
 ultrasound improves accuracy of glenoid labrum) 
injection  can combine diagnostic arthroscopy
 most patients do not experience long term with open distal clavicle resection
 relief after injections  open procedures require meticulous
 repair of deltotrapezial fascia
o
Traumatic Anterior o Arthroscopic Bankart repair +/- capsular shift     
Shoulder Instability o acute reduction, ± immobilization, followed by indications
(TUBS) therapy relative indications
indications first-time traumatic shoulder dislocation
management of first-time with Bankart lesion confirmed by MRI in athlete younger than 25 years of
dislocators remains controversial age
risk factors for re-dislocation are high demand athletes
age < 20 (highest risk) recurrent dislocation/subluxation (> one
male dislocation) following nonoperative management 
contact sports < 20-20% glenoid bone loss 
hyperlaxity remplissage augmentation with
glenoid bone loss >20-25% arthroscopic Bankart may be considered if Hills-Sachs "off-track"
reduction outcomes
simple traction-countertraction is results now equally efficacious as open repair with
most commonly used the advantage of less pain and greater motion preservation
relaxation of patient with sedation o Open Bankart repair +/- capsular shift
or intraarticular lidocaine is essential indications
immobilization Bankart lesion with glenoid bone loss < 20-
studies have not shown any
benefit of immobilization > 1 week for decreasing recurrence 25%        
revision stabilization following failed arthroscopic
rates  Bankart repair without glenoid bone loss >20%
some studies show immobilization humeral avulsion of the glenohumeral ligament
in external rotation decreases recurrence rates in patients < 40 (HAGL)
thought to reduce the can also be performed arthroscopically but
anterior labrum to the glenoid leading to more anatomic healing is technically challenging
subsequent studies have o Latarjet (coracoid transfer) and Bristow Procedures for
refuted this finding and the initially published results have not
been reproducible glenoid bone loss   
physical therapy indications
strengthening of dynamic chronic bony deficiencies with >20-25% glenoid
stabilizers (rotator cuff and periscapular musculature)  deficiency (inverted pear deformity to glenoid)     
transfer of coracoid bone with attached conjoined
 tendon and CA ligament 
Latarjet procedure performed more commonly than
Bristow
Latarjet triple effect = bony (increases glenoid
track), sling (conjoined tendon on top of subscapularis), capsule
reconstruction (CA ligament)
o Autograft (tricortical iliac crest) or allograft (iliac crest or
distal tibia) for glenoid bone loss
indications
bony deficiencies with >20-25% glenoid deficiency
(inverted pear deformity to glenoid) 
revision of failed latarjet
o Remplissage technique for Hill Sachs defects 
indication
engaging large (>25-40%) Hill-Sachs defect 
"off-track" Hill-Sachs lesions with <20-25% glenoid
bone loss 
technique
posterior capsule and infraspinatus tendon sutured
into the Hill-Sachs lesion
may be performed with concomitant Bankart repair
o Bone graft reconstruction for Hill Sachs defects
indication
engaging large (>40%) Hill-Sachs lesions
technique
allograft reconstruction
arthroplasty
rotational osteotomy
o Historical procedures: Putti-Platt / Magnuson-Stack / Boyd-
Sisk
all procedures some variation of tightening subscapularis
(advancment, plication, etc)
led to over-constraint and arthrosis
typical presentation of open procedure performed
 in 1970s-80s, now with presenting complaint of pain and stiffness from
glenohumeral OA, especially lack of ER, and signigicant posterior glenoid
wear and retroversion 
o
Posterior Shoulder  acute reduction and immobilization in external  open or arthroscopic posterior labral repair (Bankart)  
Instability & rotation for 4 to 6 weeks o indications
Dislocation o indications  recurrent posterior shoulder instability despite
 should be initially attempted for all acute appropriate course of physical therapy 
traumatic posterior dislocations  continued pain with loading of arm in forward
o most dislocations reduce spontaneously flexed position (bench press, football blocking)
o technique  negative Beighton score
 immobilize in 10-20 degrees of external o outcomes
rotation with elbow at side  80% to 85% success at 5- to 7-year follow-up after
 after 6 weeks advance to physical therapy open repair
(rotator cuff strengthening and  similar outcomes with arthroscopic repair after
periscapular stabilization) and activity shorter follow-ups 
modification (avoid activities that place  open or arthroscopic posterior capsular shift and rotator
arm in high-risk position) interval closure
 physical therapy  o indications
o may be a first line treatment for chronic posterior instability  positive Beighton score
with rotator cuff strengthening, periscapular stabilizers may  posterior glenoid opening wedge osteotomy
be considered for the in-season athlete  o indications
  excessive congenital glenoid retroversion
 limited studies assessing outcomes with this
approach 
 open reduction with subscapularis transfer (McLaughlin) or
lesser tuberosity transfer to the defect (Modified
McLaughlin) 
o indications
 chronic dislocation < 6 months old
 reverse Hill-Sachs defect < 40%
 hemiarthroplasty
o indications
 chronic dislocation > 6 months old
  severe humeral head arthritis
 collapse of humeral head during reduction
 reverse Hill-Sachs defect > 40% of articular
surface 
 total shoulder arthroplasty
o indications
 significant glenoid arthritis in addition to one of the
hemiarthroplasty indications
o
Multidirectional  o capsular shift / stabilization procedure (open or arthroscopic)
Shoulder Instability o dynamic stabilization physical therapy  indications
(MDI)  indications  failure of extensive nonoperative
 first line of treatment  management  
 vast majority of patients   pain and instability that interferes with ADLs
 technique of sports activities
 3-6 month regimen needed  contraindications
 strengthening of dynamic  voluntary dislocators
stabilizers (rotator cuff and o capsular reconstruction (allograft)
 rare, described in refractory cases and patients
periscapular musculature)      with collagen disorders
o
 closed kinetic chain exercises are
used early in the rehabilitation
process to safely stimulate co-
contraction of the scapular and
rotator cuff muscles 

Luxatio Erecta  o arthroscopic or open repair

(Inferior o closed reduction and immobilization  indications 
Glenohumeral Joint  indications  active younger patients
Dislocation)  inactive elderly patients  advantage of arthoroscopic approach
 may be considered in the absence  allows assessment and addressing multiple
of acute traumatic rotator cuff tear  concomitant pathologies including
 technique  capsulolabral damage
 traumatic rotator cuff tear
  traction-countertraction  prompt surgical repair for
 similar technique as for acute RTC tear typically
anterior shoulder recommended 
dislocations  prolonged non-operative
 two-step technique treatment may result in
 converts inferior dislocation significant retraction and
to anterior dislocation rapid progression to
 clinician stands at patient's nonrepairable condition
head, pushes laterally on  technique
humerus (one hand) while  repair vs reconstruction of shoulder
pulling superiorly on medial pathology
epicondyle (other hand), o
which should rotate HH
from inferior to anterior
around the glenoid rim
 when successful,
shoulder position
will have changed
from abduction to
adduction against
chest wall
 then use any anterior-
dislocation technique to
reduce shoulder 
 post-reduction
 brief period of immobilizer
 followed by ROM exercises
assuming intact rotator cuff
 physical therapy should focus on
periscapular and rotator cuff
strengthening

SLAP Lesion  o arthroscopic debridement 
o rest from sports followed by physical therapy and  indications
NSAIDs  Types I, III, and IV tears involving <1/3rd of
  indications the biceps tendon, causing severe
 first line of treatment symptoms that have failed nonoperative
 address GIRD if present management
 rehab focusing on scapular o arthroscopic debridement with repair of the labrum/biceps
dyskinesia and rotator cuff versus debridement with biceps tenotomy/tenodesis
strengthening for all patients  indications
 highly controversial
  Type 2 tears traditionally repaired in
overhead athletes 
 return to play rates after SLAP
repairs are significantly lower for
pitchers compared to non-
pitchers 
 general consensus bodes for tenotomy for
among those over 40 years of age
o arthroscopic debridement with repair or debridement of the
labrum with biceps tenotomy/tenodesis
 indications
 Type IV tears with >1/3rd of the biceps
tendon involved, causing severe symptoms
that have failed nonoperative management
o
Internal Impingement  o arthroscopic debridement of rotator cuff and/or labrum 
o PT, cessation from throwing, posterior capsule  indications
stretching   failure of nonoperative treatment and 
 indications  partial thickness rotator cuff tear
 first-line of treatment (PASTA) that compromise the
 most internal impingement can be integrity of the rotator cuff
treated non-operatively  partial rotator cuff
 Operative treatment should only tears <50%  
be considered if patient has failed  Bennett lesions
adequate physical therapy for an  peel-back labral lesion
extended period of time as results o Arthroscopic vs mini-open rotator cuff and/or labral repair
folliwing operative intervention are  indications
 unpredictable   partial tears >50% tendon thickness or full
 thickness tears
 unstable labral tears
o Posterior capsule release vs anterior capsular stabilization
 indications
 persistent posterior capsule contracture or
anterior shoulder instability in addition to
any of the above pathology
o
  o posteroinferior capsule release vs. anterior stabilization 
 8 o rest from throwing and physical therapy for 6 months  indications
Glenohumeral  indications  only indicated if extensive PT fails
Internal Rotation  first line of treatment   o
Deficit (GIRD)  physical therapy 
 posteroinferior capsule
stretching 
 sleeper stretch        
 
 performed
with internal rotation
stretch at 90
degrees
abduction with
scapular
stabilization     

 roll-over sleeper stretch   

 arm flexed 60° and
body rolled forward
30°
 doorway stretch   
 cross-body adduction
 stretch   
 pectoralis minor stretching   
 rotator cuff and periscapular
strengthening
 outcomes
 90% of young throwers respond to
sleeper stretches/PT
 10% of older throwers do not
respond, and will need
arthroscopic release eventually

Little Leaguer's  o
Shoulder o cessation of throwing, followed by PT and progressive
throwing program after sufficient rest 
 indications
 mainstay of treatment
 technique
 refrain from pitching for 3 months
 start progressive throwing
program only after
symptom resolution
 physical therapy
 rotator cuff strengthening
 posterior shoulder capsule
stretching
 core strengthening
 progressive throwing program
 start with short tosses at
low velocity
 slowly progress distance
and velocity of throws
 Prevention
o proper pitching mechanics
 using pitching coaches
 o discourage breaking ball pitches
 until skeletal maturity
o enforcement of pitch counts
 as well as days off for shoulder rest
o avoid year-round pitching

Posterior Labral Tear  o posterior labral repair, capsulorrhaphy 
o activity modification, NSAIDs, PT  indications
 indications  extensive nonoperative management fails
 first line of treatment  technique
 technique  arthroscopic and open techniques may be
 rotator cuff and deltoid used
strengthening  arthroscopic preferred to open given
 periscapular stabilization the extensive posterior surgical
dissection required
 more reliable return to play
 suture anchor repair and capsulorrhaphy
results in fewer recurrences and
revisions than non-anchored repairs
 probing of posterior labrum is required to
rule out a subtle Kim lesion 
 outcomes
 generally good
 return to previous level of function in
overhead throwing athletes not as
reproducible as other athletes
 failure risk increases if adduction and
internal rotation are not avoided in the
acute postoperative period 
o
Suprascapular notch  o surgical nerve decompression at suprascapular notch 
entrapment o activity modification and organized shoulder rehab  indications
program   structural lesion seen on MRI (cyst)
  indications  failure of extended nonoperative
 no structural lesion seen on MRI management (~ 1 year)
 technique o
 rehab should be performed for a
minimum of 6 months

Spinoglenoid notch  o labral repair with or without arthroscopic cyst
entrapment o activity modification and organized shoulder rehab decompression   
program   indications
 indications  labral lesion with associated cyst seen on
 no structural lesion seen on MRI MRI
 technique o spinoglenoid ligament release with nerve decompression 
 posterior shoulder capsule  indications
stretching  no structural lesion seen on MRI and failure
of extended nonoperative management (~ 1
year)
 technique
 posterior approach commonly utilized
 decompress nerve in spinoglenoid notch
o
Medial Scapular  o early repair of serratus anterior avulsion
Winging o observation, physical therapy and activity modification  indications
 indications  mechanical disruption of the serratus
 observe for a minimum of 6 anterior muscle (avulsion) and/or its
months, ideally 18 months to 2 insertion (inferior pole scapula fractures)
years with symptomatic winging should undergo
 wait for nerve to recover surgical repair acutely
 technique o neurolysis of the long thoracic nerve
 physical therapy for serratus  indications
anterior strengthening, stretching  failure to improve with conservative
 avoid painful or heavy lifting treatment, at least 6 months
activities  electromyography with signs of nerve
 bracing with a modified compression (distal latency, dennervation)
thoracolumbar brace can be  technique
 considered  supraclavicular decompression as the
 poor compliance and little nerve traverses the scalene muscles
benefit  outcomes
 outcomes  excellent improvement in pain and
 majority of patients will resolution of winging in patients who failed
spontaneously resolve with full nonoperative management (98%)
return of shoulder function and  better improvement in shoulder strength
resolution of winging by 2 years (flexion and abduction) compared to muscle
transfers
o muscle transfer: split pectoralis major transfer 
 indications
 failure to improve with conservative
treatment, for 1-2 years
 pain relief and improved shoulder function
with manual scapular stabilization
 technique
 split pectoralis major transfer (sternal
head) 
 with or without augmentation with a
fascia lata or hamstring graft
 most effective
 other transfers
 pectoralis minor transfer
 rhomboid transfer
 outcomes
 predictor of successful surgery is symptom
relief and improved function with
preoperative manual scapular stabilization
 often have persistent shoulder abduction
weakness
 complications
 failure of pectoralis muscle transfer
attachment at scapula
 unsatisfactory cosmesis (breast
asymmetry in women)
  infection
 adhesive capsulitis
o nerve transfer
 developing area in the microsurgical field
 technique
 lateral branch of the thoracodorsal nerve to
the long thoracic nerve
 medial pectoral nerve with sural nerve graft
to the long thoracic nerve
 outcomes
 shown to successfully reinnervate the long
thoracic nerve
 benefit of preserving proper muscle
biomechanics
o scapulothoracic fusion
 indications
 scapular winging from diffuse
neuromuscular disorders
 failed muscle transfer surgery
 often not the first surgical treatment of
choice
 primary goal is pain relief
 technique
 fusion of the anterior scapula to the
posterior rib cage, with wire cables and/or
plates and screws
 outcomes
 limited increase in shoulder motion
 ~20° gain of abduction
 recent studies show high satisfaction levels
in 82% of patients at 5-year follow up
 complications
 nonunion
 pleural effusion
 adhesive capsulitis
  symptomatic hardware requiring
removal
o
Lateral Scapular  o exploration of the spinal accessory nerve, neurolysis, repair
Winging o observation, physical therapy and activity modification  indications
 indications  identifiable nerve injury diagnosed early
 the role of conservative  technique
management is controversial given  should be performed within 20 months of
that most injuries are iatrogenic injury
direct nerve injuries and warrant o muscle transfer: Eden-Lange transfer   
surgical intervention  indications
 elderly and sedentary patients and  nerve injury diagnosed late (> 20 months
those without an identifiable from injury)
injury should be initially treated  technique
conservatively  transfer of the levator scapulae and
 outcomes rhomboid muscles from the medial border
 predictors of a poor outcome with of the scapula to the lateral border, to
conservative management include effectively reconstruct the trapezius
inability to raise the arm above the o scapulothoracic fusion
shoulder at presentation and  see above under Medial Scapular Winging
dominant extremity involvement o

Brachial Neuritis  o nerve exploration, neurolysis, neurorrhaphy, nerve grafting,

(Parsonage-Turner o observation and pain control nerve transfer or muscle/tendon transfers
Syndrome)  indications  indications
 mainstay of treatment  no evidence of regeneration or early
 technique recovery in a nerve distribution by 6-9
 during the early pain phase, pain months on physical examination and EMG
control is paramount studies
 NSAIDs  technique
 judicious use of narcotic  neurolysis
medications, slow-release  long thoracic nerve microneurolysis
 immobilization   ulnar nerve transposition, Guyon
 oral corticosteroids (see canal release
below)  radial tunnel release
  follow patients monthly for  carpal tunnel release
improvement  neurorrhaphy and nerve grafting
 can use both physical  excision of diseased nerve segment
exam and serial EMGs to and either direct repair
follow neurologic recovery (neurorrhaphy) or nerve grafting
 outcomes  nerve transfers
 at 1 year, observation alone  muscle / tendon transfers
results in similar functional  split pectoralis major transfer for
outcomes compared to serratus anterior paralysis
observation with physical therapy   outcomes
 prognosis is good with most  surgical exploration of patients with INA
patients making a complete without neurologic recovery revealed
recovery, but progress is slow hourglass-like constrictions in the
 at 1 year, only 35% of peripheral nerves with no external
patients have recovered compression
 at 3 years, 90% of patients  neurolysis alone was superior to
have recovered full muscle neurorrhaphy and nerve grafting
strength and function with o
no residual pain or
deficits 
o physical therapy
 indications
 once severe pain has abated and
weakness is the primary issue
 technique
 shoulder girdle strengthening and
range of motion
 pain relief strategies to alleviate
traction on the involved nerves
 outcomes
 reverses atrophy and improves
muscle bulk comparable to
contralateral unaffected side
o oral corticosteroids
 indications
  severe pain during early pain
phase
 technique
 two week course of 1mg/kg/day of
prednisone followed by a two week
taper
 outcomes
 some evidence that this regimen
may lead to a more rapid
resolution of the pain phase, but
does not affect the progression or
prognosis

Thoracic Outlet  o thoracic outlet decompression 

Syndrome o activity modification, pain control, physical therapy and  indications
modalities  symptoms that have failed conservative
 indications  treatment for 6 months
 first line of treatment  progressive muscle atrophy and/or
 technique  worsening neurologic deficits
 activity modification to avoid  technique
provocative activities  decompression includes a combination of
 limiting repetitive overhead the following depending on etiology
motion  first rib resection, anterior and
 changing employment if middle scalenectomy, neurolysis
necessary  most common procedure
 pain control   95% good outcomes
 NSAIDs, muscle relaxants  isolated scalenectomy
 physical therapy  indications
 core and back
 upper plexus
strengthening, shoulder
symptoms
girdle strengthening,
improving posture and  absence of abnormal
relaxation techniques bony architecture
 modalities   excessively muscular
 transcutaneous electrical or obese patients
 nerve stimulation  recurrent TOS
 outcomes  following prior first rib
 less successful in  resection
 obese patients  isolated pectoralis minor tenotomy
 patients on worker's  indications
compensation  neurogenic TOS with
 patients with double-crush symptoms
neurologic pathology reproducible to the
involving the carpal or retropectoralis minor
cubital tunnels spacw
o anterior scalene blocks  cervical rib resection
 indications   release of fibromuscular bands
 neurogenic TOS related to scalene  costoclavicular ligament resection
muscule contracture  ORIF of clavicle malunion
 technique  o vascular intervention
 ultrasound-guided lidocaine or  indications
botulinum toxin injections  embolic events
 outcomes   stenosis with persistent pain and vascular
 successful block correlates with insufficiency
14% higher rate of good surgical  subclavian aneursym
outcomes  thrombosis with critical ischemia
 technique indications
 heparin IV, +/- embolectomy, +/- local
thrombectomy, +/- TPA, systemic
anticoagulation
 acute embolic event
 small vessel embolism - TPA,
systemic anticoagulation
 large / proximal vessel embolism -
embolectomy, systemic
anticoagulation
 endovascular stent placement
 mild stenotic disease
 vascular resection +/- primary repair, +/-
saphenous vein graft, +/- arterial autograft,
 +/- synthetic graft
 subclavian aneursym
 severe stenosis or thrombosis with
critical ischemia
 vascular bypass
 chronic emboli with critical ischemia
o
Quadrilateral Space  o nerve decompression
Syndrome o NSAIDS, activity restriction, physiotherapy  indications
 indications  failure of nonoperative management 
 first line of treatment   significant weakness and functional
 techniques disability
 glenohumeral joint mobilization  decompression of space-occupying lesion
and strengthening  techniques
 posterior capsule stretching  open release of quadrilateral space +/-
 massage arthroscopic repair of labral tear
 outcomes o
 most people improve with 3-6
months of nonoperative treatment
o diagnostic lidocaine block 
 indications
 will help to confirm diagnosis
 technique
 inject plain lidocaine directly into
the quadrilateral space 
 starting point is 2 to 3 cm inferior
to the standard posterior shoulder
arthroscopy portal
 outcomes
 positive if no point tenderness or
pain with full ROM of the shoulder
following injection

Pectoralis Major  o open primary repair
Rupture o initial sling immobilization, rest, ice, NSAIDs, physical  indications 
 therapy  gold standard for acute tears in high level
 indications athletes, and most young, active
 low-demand, patients 
sedentary, and elderly patients   tendon avulsion, myotendinous junction
 muscle belly tears, low-grade
partial ruptures tears    
 outcomes  outcomes
 inferior to operative management  reliable strength recovery, return to sport,
for young, active individuals and patient satisfaction 
 cosmetic disfigurement, significant  may show improvement regardless of
deficit in strength (most location of tear
pronounced with isokinetic  excellent success with all methods 
adduction) and peak torque,  some evidence suggests that
delayed recovery, poor patient cortical button fixation
satisfaction, lower return to and transosseous suture repair with
competitive sports cortical trough are superior to suture
anchor repair
o reconstruction
 indications
 chronic tears that cannot be adequately
mobilized for primary repair 
 primary repair may still be possible
years after the injury
 persistent strength deficit in chronic tears
 outcomes 
 reliable strength recovery and patient
satisfaction, albeit generally inferior to
primary repair
 still significantly better than nonoperative
management in young, active patients
o
Latissimus Dorsi  o primary repair vs reconstruction
Rupture o short period of rest followed by PT  indications
 indications  for high demand athletes (currently there
 allow resumption of activities in low are no defined indications for surgical
 demand patients repair)
 technique  technique
 physical therapy goals are to  early primary repair is favored to prevent
restore shoulder motion and retraction and scarring
strength o
 throwing can be allowed
 after full, pain-free motion
and good strength
 balance of the rotator cuff
and scapular rotator
muscles

Glenohumeral  o total shoulder arthroplasty (TSA)  

Arthritis o physical therapy, NSAIDs  indications
 indications  intact rotator cuff
 first-line of treatment  unresponsive to non-operative treatment
 modalities  glenoid chondral wear
 NSAIDs- reduce pain and  posterior humeral head subluxation
inflammation  contraindications
 physical therapy – improve range
 lack of deltoid or rotator cuff function 
of motion with capsular stretching
 active infection
o intraarticular Injections
 Charcot arthropathy
 indications
 technique
 second-line of treatment
 concave glenoid (cup) and convex humerus
 modality
(ball) to reconstruct joint
 corticosteroid injection – reduce
 outcomes
pain/inflammation
 good pain relief, reliable ROM
 hyaluronic acid injection – joint
 10 year survival (92-95%)
lubrication, limited evidence
 most common complications:
 biologics (platelet rich plasma,
glenoid/humeral component loosening,
stem cell) – limited evidence
infection, fracture, nerve injury and rotator
o DMARDs
cuff tear
 indications o hemiarthroplasty
 rheumatoid arthritis
 indications
  younger patient
 rheumatoid arthritic patients with
irreparable RC tears/insufficient bone stock
 osteonecrosis without glenoid involvement
 technique
 humeral head replacement ± biologic
resurfacing
 ream-and-run technique
 humeral head prosthesis & glenoid
reaming to provide a stabilizing
concavity and maximize
glenohumeral contact area for load
transfer
 indicated in young patients with
intact rotator cuff and no inflamatory
arthropathy
 outcomes 
 early failure rate, not recommended
 poor pain and functional outcomes
o reverse shoulder arthroplasty (RSA) 
 indications
 irreparable/large rotator cuff tear 
 OA or RA with significant glenoid
pathology 
 age
 rotator cuff arthropathy
 failed arthroplasty
 complex fracture
 technique
 convex glenoid (ball) and concave humerus
(cup) to reconstruct joint
 outcomes
 Good pain relief, improved shoulder
function
  10 year survival (~90-95%)
 Common complications:  scapular notching,
infection, dislocation/instability, nerve
injuries; higher reported complication rates
than TSA
o arthroscopic debridement 
 indications
 mild to moderate OA without structural
alternation
 mechanical symptoms due to loose bodies
or small lesions of humeral head due to
AVN
 synovial chondromatosis
 outcomes
 temporizing treatment; improves ROM and
pain
 less successful in those with more rapid
degenerative changes
 may see better results in patients who also
had subacromial procedures
o CAM (comprehensive arthroscopic management) procedure
 indications
 younger patient
 technique
 combination of arthroscopic glenohumeral
debridement, chondroplasty, synovectomy,
loose body removal, humeral osteoplasty
with excision of the goat's beard
osteophyte, capsular releases, subacromial
and subcoracoid decompressions, axillary
nerve decompression, and
biceps tenodesis
o arthrodesis
 indications
 paralysis
  recurrent infection
 severe soft tissue deficiency; poor deltoid
function
 brachial plexus palsy
 persistent symptomatic instability with failed
repair
 outcomes
 moderate complications
 Improved/ acceptable long-term function
o
Avascular Necrosis of  o core decompression + arthroscopy (confirm integrity of
the Shoulder o pain medications, activity modification, physical therapy cartilage)   
 indications indications

 first line of treatment  early disease (precollapse Cruess Stage I
 technique and II)
 physical therapy o humeral head resurfacing
 restrict overhead activity  indications
and manual labor  Stage III disease with focal chondral
defects, and sufficient remaining epiphyseal
bone stock for fixation.
o hemiarthroplasty   
 indications
 moderate disease (Cruess Stage III and IV)
o total shoulder arthroplasty 
 indications
 advance stage (Cruess V)
o
Neuropathic (Charcot)  o neurosurgical decompression
Joint of Shoulder o rest, NSAIDs, protected immobilization with a sling,  indications
restriction of activity and treatment of underlying  presence of cervical syrinx
disease  outcomes
 indications  decompression of syrinx has shown to slow
 first line treatment for neuropathic disease progression, maximize joint
function and improve bone quality
 shoulder joint  studies have shown regrowth of
 outcomes glenoid fossa following syrinx
 50% of patients reported decompression
improvement after non-operative o shoulder arthrodesis
management  indications
o intra-articular corticosteroid injection  severe charcot shoulder pain having failed
 indications conservative management
 severe shoulder pain   outcomes
 outcomes  previously was only operative management
 some case reports have shown offered for charcot shoulder
temporary 80% reduction in pain o shoulder arthroplasty 
following glenohumeral CSI  indications
 neuropathy arthropathy is listed as STRICT
contraindication for majority of FDA-
approved shoulder arthroplasties due to
concerns of prosthetic loosening
 arthroplasty for this condition should be
physician-directed application or off-label
use
 newer literature states that arthroplasty is a
viable option for patients with charcot
shoulder who have failed conservative
management and have had underlying
condition treated/managed
 outcomes
 70% patients reported improved function
with off-label hemiarthroplasty or reverse
TSA combined with physical therapy at 5
year followup 
o
Adhesive Capsulitis  o manipulation under anesthesia (MUA)
(Frozen Shoulder) o physical therapy, NSAIDs and/or intra-articular steroid  indications 
injections, heat and/or cryotherapy   failure to improve with non-operative
 indications modalities
  first-line treatment, often effective  contraindications
 physical therapy program  controversial if done during
of gentle, pain-free stretching and freezing/inflammatory phase 
moist heat   diabetics- 50% failure rate
 should be supervised and last for  following rotator cuff or labral repair
3-6 months o arthroscopic or open capsular release   
o distension arthrography  indications
 rarely performed  after extensive therapy has failed (3
months)
 arthroscopy will spare subscapularis
tendon with the advantage of releasing
intra-articular and subacromial adhesions
o
Shoulder  o conversion to prosthetic stem spanning fracture site by two
Periprosthetic o immobilization  cortical diameters
Fracture  indications  indications
 long oblique or spiral type A or B  intraoperative type A fractures
fractures with a stable prosthesis o conversion to proximally porous coated long stem prosethesis
 type C fracture spanning fracture site by two to three cortical diameters
 outcomes:  indications
 union rates <50%  intraoperative type B fractures
 intraoperative type C fractures
o open reduction and internal fixation 
 indications
 intraoperative fractures
 type C unamenable to long stem
prosthesis
 postoperative fractures
 transverse type A and B fractures
with stable prosthesis
 type C that has failed nonsurgical
management
 patients unable to tolerate
nonoperative management
 o revision arthroplasty with supplementary fixation 
 indications
 presence of a loose prosthesis with any
fracture type
 long stem prosthesis
 poor bone stock
 bypass fracture by two cortical diameters
 short stem prosthesis
 good bone stock
 convert to a shorter stem prosethesis than
original and apply supplementary fixation
o
Medial Ulnar  o UCL anterior band ligament reconstruction (Tommy John
Collateral Ligament o Rest and physical therapy Surgery) 
Injury (Valgus  indications  indications
Instability)  first line treatment in most  high-level throwers that want to continue
cases    competitive sports
 partial tears  failed nonoperative management in partial
 outcomes tears and willing to undergo extensive
 42% return to preinjury level of rehabilitation
sporting activity at an average of  outcomes 
24 weeks  90% return to preinjury levels of throwing
 with newer reconstruction techniques
 humeral docking associated with better
patient outcomes and lower complication
rate compared to figure-of-8 fixation 
 humeral docking has shown higher rates of
return to sport compared to Jobe and
modified Jobe techniques 
 humeral docking and cortical button
techniques are biomechanically stronger
than figure-of-8 and interference screw
fixation
 humeral docking with interference screw
 fixation on the ulnar side showed 95%
strength of the native UCL
o UCL repair
 indications
 not clarified in the literature
 mostly performed in young athletes with
avulsion-type tear patterns
 outcomes
 originally performed with poor results,
replaced by reconstruction
 multiple, recent case series show promising
results with novel, augmented techniques
o
Valgus Extension  o resection of posteromedial osteophytes, removal of loose
Overload (Pitcher's o NSAIDS, throwing rest, activity modification, steroid bodies, debridement of chondromalacia
Elbow)  indications
injections 
 indications  persistent symptoms that fail to improve
 first line of treatment with nonoperative treatment
 technique  contraindications
 flexor-pronator strengthening  MCL insufficiency is a relative
 pitching instructions to correct poor contraindication for olecranon debridement
technique alone
 technique

 may be arthroscopic or open
 arthroscopy procedures can include
debridement or drilling of chondromalacia,
debridement of lateral meniscoid lesion or
posterolateral plica, osteophyte excision,
loose body excision
 care must be taken to only remove
osteophytes and not normal olecranon as
this many result in a loss of bony restraint
and increase the tension in the MCL 
o
Little League Elbow  o ORIF of medial epicondyle
o rest, activity modifications, PT  indication
 indication  for medial epicondyle avulsion fractures
 is the mainstay of treatment o UCL reconstruction
 technique  indication
 coach and parent education is  for UCL disruption and insufficiency
critical to limit number of innings o
pitched per week
 use minimal immobilization to
maintain elbow ROM

Olecranon Stress  o open internal fixation
Fracture o short-term administration of NSAIDS, rest +/- temporary  indications
splinting  delayed fracture union 
 indications  modalities
 first-line treatment   large compression screw   
 modalities  tension band wire 
 initial 4-6 weeks of rest or splintingo
 progressive ROM exercises
 avoiding valgus loading forces
(e.g. throwing)
 electrical bone stimulation may
also be considered

Lateral Ulnar  o open reduction, fracture fixation, LUCL repair
Collateral Ligament o acute reduction followed by immobilization at 90° flexion  indications
Injury (PLRI) for 5-7 days   osteochondral fragment or soft-tissue
 indications entrapment prevents concentric reduction
 acute elbow dislocations  complex dislocation (associated fractures
 technique are present)
 following reduction assess post-  acute instability
reduction stability  open & arthroscopic techniques
 place in posterior splint for 5-7 described
days, with elbow at 90 degrees of o LUCL reconstruction w/ graft
 flexion and forearm appropriately  indications
positioned based on post-  chronic PLRI 
reduction stability o
 LCL disrupted, but MCL
intact 
 splint in full
pronation (tightens
lateral structures)
 LCL + MCL disrupted
 splint in neutral
 will not splint in full
supination (for MCL rupture
only) as the LCL is always
disrupted in PLRI
 early active ROM following splint
removal (+/- extension block)
 full supination/pronation
from 90° to full flexion
 progress with increasing
extension by 30° weekly,
but with the forearm in full
pronation; after 6 weeks full
supination in extension
allowed
o bracing, extensor strengthening, activity modification w/
avoidance of gravity varus positions 
 indications
 mild, chronic PLRI
 low-demand patients

Distal Biceps  o surgical repair of tendon to tuberosity 
Avulsion o supportive treatment followed by physical therapy  indications
 indications  young healthy patients who do not want to
 older, low-demand or sedentary
sacrifice function   
 patients who are willing to sacrifice  partial tears that do not respond to
function  nonoperative management
 if the lacertus fibrosis is intact, the  subacute/chronic ruptures may be treated
functional deficits of biceps rupture successfully with direct repair (without
may be minimized in a low- allograft)
demand patient.   
 outcomes  may need to hyperflex elbow to
 will lose 50% sustained supination achieve fixation
strength  hyperflexion does NOT lead to loss
 will lose 40% supination strength of elbow ROM or flexion contracture
 will lose 30% flexion strength  timing
 will lose 15% grip strength  surgical treatment should occur within a few
 weeks from the date of injury
 further delay may preclude a
straightforward, primary repair.
 a more extensile approach may be
required in a chronic rupture to
retrieve the retracted and scarred
distal biceps tendon.
o
Triceps Rupture  o primary surgical repair
o splint immobilization  indications
 indications  acute complete tears
 partial tears and able to extend  partial tears (>50%) with significant
against gravity weakness
 low demand patients in poor health  technique
 techniques  delayed reconstruction may need tendon
 immobilize elbow in 30 degrees of graft 
flexion for 4 weeks o

Lateral Epicondylitis  o release and debridement of ECRB origin

(Tennis Elbow) o activity modification, ice, NSAIDS, physical therapy,  indications
ultrasound  if prolonged nonoperative (6-12 months)
 indications fails
 first line of treatment  clear diagnosis (isolated lateral
  techniques epicondylitis)
 tennis modifications (slower  intra-articular pathology 
playing surface, more flexible  contraindications
racquet, lower string tension,  inadequate trial of nonsurgical treatment
larger grip)  patient noncompliance with the
 counter-force brace (strap) recommended nonsurgical treatment
 steroid injections (up to three)   o

 physical therapy regimen 

 acupuncture
 iontophoresis/phonophoresis
 extracoproeal shock wave therapy
 outcomes
 up to 95% success rate with
nonoperative treatment, but
patience is required

Medial Epicondylitis  o open debridement of PT/FCR, reattachment of flexor-pronator
(Golfer's Elbow) o rest, ice, activity modification (stop throwing x 6-12wks), group
PT (passive stretching), bracing, NSAIDS  indications
 indications  up to 6 months of nonoperative
 first line of treatment management that fails in a compliant
 prolonged trial of conservative patient
management appropriate due to  symptoms severe and affecting quality of
less predictable success of life
operative treatment (compared to  clear diagnosis
lateral epicondylitis)  outcomes
 technique  good to excellent outcomes in 80% (less
 counter-force bracing / kinesiology than lateral epicondylitis)
taping  worse outcomes when ulnar nerve
 ultrasound shown to be beneficial symptoms present pre-operatively
 multiple corticosteroid injections o
should be avoided
o extracorporeal shockwave therapy (ESWT)
  no definitive recommendations at present
 promotes angiogenesis, tendon healing,
short term analgesia
o corticosteroid injections into peritendinous tissue 
 complications
 skin depigmentation (if dark
skinned)
 subcutaneous atrophy
 tendon weakening
 ulnar nerve injury
o acupuncture

Flexor Pronator Strain  o primary surgical repair
o NSAIDS, rest, physical therapy, steroid injections  indications
 indications  significant (>2.5 cm) retraction 
 first line of treatment  o
 technique
 ROM and flexor pronator
strengthening x 4-6 weeks
 corticosteroid injection for chronic
flexor pronator tendonitis
 rarely needed
 avoid UCL due to risk of
rupture
 outcomes
 typical resolution and return to
sport in 4-6 weeks

Elbow Arthritis  o arthroscopic debridement and capsular release     
o NSAIDS, cortisone injections, resting splints, and  indications
activity modification  mechanical symptoms from loose bodies
 indications  stiffness related to capsular contracture
 mild to moderate symptoms  stiffness related to bony block to motion
  preferred in patients with >90° of motion
  contraindications
 Prior ulnar nerve transposition
 severe contracture or arthrofibrosis
 technique
 removal of osteophytes and loose bodies
 Capsular release
 complications
 neurologic injury
 synovial fistula
 recurrence of stiffness
o ulnohumeral distraction interposition arthroplasty
 indications
 young, high demand patients with END
STAGE arthritis (OA, RA, post-traumatic
arthritis who would otherwise have received
TEA if they were older)
 technique
 can use
 autogenous tensor fascia lata
 achilles tendon allograft
 complications
 patients with severely limited preoperative
motion (max extension > 60° and flexion <
100° are at risk for ulnar nerve
dysfunction postoperatively
 should undergo a concomitant ulnar
nerve decompression/transposition
o olecranon fossa debridement (Outerbridge-Kashiwagi
procedure)   
 indications
 younger patients with decreased ROM
 technique
 burr hole through olecranon fossa
 removes osteophytes and arthritic
bone
  increases range of motion
 be sure to decompress the ulnar nerve if
there is an flexion contracture
preoperatively
 complications
 failure to address anterior osteophytes or
peripheral osteophytes on medial and
lateral olecranon.
o column procedure - medial or lateral open capsular release and
bony resection
 indications 
 extrinsic contracture of the elbow that
causes functional loss of extension and/or
flexion
 most common technique; go medial if need
to gain flexion by excising posterior band of
MCL
o total elbow arthroplasty
 indications
 older patients >65 years with severe elbow
arthritis (Larsen stage 3-5)
 complex distal humerus fracture in elderly
with poor bone stock
 distal humerus nonunion or malunion in
elderly, lower demand
 post-traumatic arthritis
 contraindications
 highly active patient <65
 infection
 Charcot joint
 complications (as high as 43%)
 infection
 instability
 loosening
 wound healing problems
  triceps insufficiency
 ulnar neuropathy
o
Neuropathic (Charcot)
o neurosurgical decompression
Joint of the Elbow o rest, NSAIDs, functional bracing, restriction of indications
activity and treatment of underlying disease presence of cervical syrinx
indications outcomes
first line treatment for neuropathic decompression of syrinx has shown to slow
elbow joint disease progression, maximize joint function and improve bone quality
outcomes studies have shown some elbow
50% of patients reported joint space restoration following syrinx decompression
improvement after non-operative management peripheral nerve neurolysis
o intra-articular corticosteroid injection indications
indications ulnar nerve palsies
severe elbow pain PIN palsies
outcomes
limited cases series have shown good
recovery of nerve function but high recurrent rates
elbow arthrodesis 
indications
elbow pain and instability having failed
conservative management
outcomes
limited case series have shown
improvement of pain but with  functional limitations 
total joint replacement
indications
 Charcot joint is considered a
contraindication to elbow total joint replacement
due to poor bone stock, prosthetic
loosening, instability, and soft-tissue compromise
outcomes
limited case reports exist on elbow
arthroplasties for charcot elbow with mixed results
o
Osteochondritis o cessation of activity +/- immobilization 
Dissecans of Elbow  indications o arthroscopic microfracture or drilling of capitellum
 type I lesions (stable fragments)  indications (separated fragments)
 technique  unstable type I lesions
 3-6 weeks followed by slow  stable type II lesions
progression back to activities over  technique
next 6-12 weeks  microfracture of chondral lesion
 outcomes  extra- or transarticular drilling of defects
 >90% success rate  post op care
 protected early range of motion
 strengthening at 2 months 
 throwing and weight bearing at 4-6 months
 outcomes
 good success rate 
o fixation of lesion
 indications
 large lesions that are incompletely
displaced
 technique
 arthroscopic reduction and fixation
 post op care
 protected early range of motion
 strengthening at 2 months
 throwing and weight bearing at 4-6 months
 outcomes
 highly variable
o arthroscopic debridement and loose body excision
 indications
 unstable type II lesion
 type III lesions
 post op care
 early range of motion +/- brace
 begin strengthening when range of motion
is painfree
 no throwing or weight bearing activities X 3
 months 
o osteochondral autograft or allograft transplantation
surgery (OATS) 
 indications
 large type II and III capitellar lesions which
engage the radial head
 uncontained lesions may require size-
matched fresh allograft
 post op care
 early range of motion
 resistive/strengthening exercises at 3
months
 progressive throwing program begins at 5
months through 7 months
o
Elbow Stiffness and o NSAIDs, physical therapy with active and passive range o capsular release +/- release of posterior band of MCL 
Contractures of motion exercises  indications
 indications  extrinsic capsular contractures with normal
 first line of treatment in most cases joint surface congruency
 contractures <40°  most predictable beneficial results
o static splinting     patients with arthritis
 indications  less predictable once joint surface is
 failed trial of physical therapy with incongruous
 elbow flexion contractures  outcomes
greater than 30° OR  compliance with postoperative rehabilitation
 elbow flexion less than is critical
130°    less predictible outcomes when ankylosis
present preoperatively
 contraindications
 charcot elbow joint
 neurologic elbow disorder
 poor skin
 relative contraindication, may need
plastic surgery (rotational flap)
 o osteophyte excision
 indications
  intrinsic contractures with arthritis confined
to olecranon fossa
 perform in conjuction with capsular release
of bony block to terminal range of motion
 bone typically should be removed
from coronoid, coronoid fossa,
olecranon, olecranon fossa
o  distraction interpositional arthroplasty 
 indications
  intrinsic contractures with diffuse arthritis in
high demand younger patients
o total elbow arthroplasty
 indications
   intrinsic contractures with diffuse arthritis
in low demand elderly patients
 outcomes
 high failure rate in young, active patients
 permanent 5-lb lifting restriction 
o musculocutaneous neurectomy
 indications
 neurogenic contractures with a flexion
deformity of less than 90 degrees
o
Revision Total Elbowo immobilization, functional elbow brace
Arthroplasty indications  o irrigation and debridement, bushing
type I humeral condylar or exchange, component retention
olecranon fractures with stable prosthesis indications 
type III humeral fractures with crepitus, squeaking +/- elbow pain with
stable implants range of motion with stable implants and no evidence of infection
patients who are not candidates (significant bushing wear)
for surgery (medical frailty, noncompliance, frequent falls) acute peri-prosthetic joint infection
length (presenting < 90 days from surgery)
length of immobilization depends outcomes
on location of fracture (2-4 weeks) in appropriate candidates without signs of
type infection, 75% result in good results at 5 year followup following isolated
transition to sarmiento (for Type III bushing exchange
humerus fractures) or functional elbow brace (for Type 1 in cases of acute infection, I&D and
fractures) component retention is 63% effective at eradicating acute infections
only 31% effective in management
of chronic infections
o open reduction and internal fixation, component
retention, +/- fracture excision, +/- strut allograft
indications
type I peri-articular olecranon fractures
type II1 fractures
type III fractures of the ulna
outcomes
80-90% patients have no complications
following isolated ORIF or excision for selected fractures
o single stage revision TEA, +/- ORIF and allograft 
indications
type II2 periprosthetic humeral shaft or ulna
fractures
aseptic loosening
outcomes
only 66% affective for errdicating chronic
TEA infection
o component explantation and 2-stage revision TEA
indications 
Mayo II2
infected periprosthetic TEA 
outcomes
success rate of eradicating chronic infection
is 90% with 2-stage revision TEA (compared to 66% for single-stage)
o resection arthroplasty   
indications
salvage procedure for treatment resistant
 PJI in patients who are unable to go multiple surgical procedures, have
severe bone loss, and severely compromised soft tissue envelope
Mayo II3 periprosthetic fractures not
amendable for reconstruction
outcomes
71% effective in completely eradication
infection
leads to the lowest functional scores (based
on Mayo Elbow Performance score
o
Meniscal Injury o rest, NSAIDS, rehabilitation
 indications partial meniscectomy
 indicated as first line treatment indications
for degenerative tears tears not amenable to repair (complex, degener
 outcomes repair failure >2 times
 improvement in knee function outcomes
following physical therapy >80% satisfactory function at minimum follow-up
 "noninferior" when compared to 50% have Fairbanks radiographic changes (oste
arthroscopic partial
predictors of success   
meniscectomy
age <40yo
 normal alignment
minimal or no arthritis
single tear
meniscal repair 
indications
best candidate for repair is a tear with the follow
peripheral in the red-red zone (vasculari
rim width is the distance from the tear to
rim width correlates with the ability of a m
supply)   
vertical and longitudinal tear
rather than radial, horizontal or d
bucket handle meniscus tear 
 1-4 cm in length
root tear   
acute repair combined with ACL reconst
traditional literature report higher
current literature shows no differe
with/without concomitant ACL reconstruction
outcomes
70-95% successful
highest success when done with concomitant A
modest result when done with an intact ACL (60
poor results with untreated ACL-deficiency (30%
meniscal transplantation
indications       
controversial 
young patients with near-total meniscectomy, es
contraindications 
inflammatory arthritis
instability
marked obesity
grade III and IV chondral changes 
malalignment (if not concurrently addressed) 
diffuse arthritis 
outcomes
requires 8-12 months for graft to fully heal
return to sports by 6-9 months 
10 year follow-up showed:
persistent improvement in subjective pai
most had radiographic progression of de
re-tears or extrusion are common 
total meniscectomy
of historical interest only
outcomes
20% have significant arthritic lesions and 70% h
 100% have arthrosis at 20 years
severity of degenerative changes is proportiona

Meniscal Cysts o rest, NSAIDS, rehabilitation o arthroscopic debridement, cyst decompression and meniscal
 indications resection
 indicated as first line of treatment  indications
for small perimeniscal cysts and  perimeniscal cysts with an associated tear
parameniscal cysts that is not amenable to repair (e.g.,
 outcomes complex, degenerative, radial tear patterns)
 trial of medical therapy to observe  technique
patients pain response  decompress cyst completely
 may be effective in population with  perform partial meniscectomy
degenerative tears  outcomes
o aspiration and steroid injection  incomplete meniscal resection may lead to
 indication recurrence
 isolated baker's cysts in young o cyst excision using open posterior approach
patient  indications
 technique  symptomatic parameniscal cysts
 cyst drainage  outcomes
 ultrasound guided injection into the  incomplete resection may lead to
cyst recurrence
 outcomes o
 poor outcomes in older
degenerative mensical tears with
associated cysts

Discoid Meniscus  o partial meniscectomy and saucerization        

o observation  indications
 indications  pain and mechanical symptoms
 asymptomatic discoid meniscus  meniscal tear or meniscal detachment
without tears     technique
  obtain anatomic looking meniscus with
debridement 
 repair meniscus if detached (Wrisberg
 variant)
o
ACL Tear o physical therapy, lifestyle modifications 
 indications  Operative
 low demand patients with o ACL reconstruction
decreased laxity  indications
 recreational athlete not  must have full motion of knee restored
participating in cutting/pivoting following injury (unless meniscal tear
activities causing mechanical block)
 outcomes  lack of pre-operative motion risk
 increased meniscal/cartilage factor for post-operative
damage linked to
arthrofibrosis 
 loss of meniscal integrity,
 younger, more active patients (reduces the
the frequency of buckling
incidence of meniscal or chondral injury)
episodes, level I and II
 children (activity limitation is not realistic)
activity (e.g. jumping,
 older active patients (age >40 is not a
cutting, side-to-side sports,
contraindication if high demand athlete)
heavy manual labor)
 partial/single bundle tears with clinical and
functional instability
 prior ACL reconstruction failure
 outcomes
 return to play largely influenced
by psychological, demographic and
functional outcomes   
o ACL repair
 indications
 previously abandoned but increased
interest recently in pediatric populations
and avulsion rupture patterns
 outcomes
 previously abandoned due to high failure
rates
 arthroscopic bridge-enhanced ACL repair
(BEAR) trial with a bridging scaffold is
 ongoing and promising   
o ACL revision reconstruction
 indications
 failure of prior ACL reconstruction with
instability during desired activities
 outcomes
 revision ACL reconstruction
 Concurrent pathology
o MCL injury
 indications
 if low grade MCL injury amenable to non-
operative treatment, allow MCL to heal prior
to ACL reconstruction
 if high grade MCL injury necessitating
repair/reconstruction, may be done
concurrently with ACL
 outcomes
 failure to address valgus instability can
jeopardize ACL graft with higher re-rupture
rates
o meniscal tears
 indications
 perform meniscal repair or meniscectomy
at time of ACL reconstruction 
 outcomes
 increased meniscal healing rate when
repaired at the same time as ACL
o chondral injuries
 indications
 partial- or full-thickness chondral injury may
be treated at time of ACL reconstruction in
staged fashion if injury necessitates
 outcomes
 presence of chondral defects consistently
 lowers long-term patient-reported outcomes
following ACL reconstruction
o posterior cruciate ligament and posterolateral corner injuries
 indications
 may reconstruct concurrently with ACL
reconstruction or as staged procedure
 outcomes
 failure to recognize and address PLC/PLC
injuries will lead to varus instability and ACL
graft overload
o high tibial osteotomy or distal femoral osteotomy   
 indications
 limb malalignment in both the coronal and
sagittal plane must be addressed before or
at the same time as ligament reconstruction
 outcomes
 high ACL failure rates in unaddressed limb
malalignment
o
PCL Injury 
o protected weight bearing & rehab
 indications
 isolated Grade I (partial) and II (complete
isolated) injuries
 modalities
 quadriceps rehabilitation with a focus on
knee extensor strengthening       
 outcomes
 return to sports in 2-4 weeks
o relative immobilization in extension for 4 weeks
 indications
 isolated Grade III injuries
 surgery may be indicated with bony
avulsions or a young athlete
  modalities
 extension bracing with limited daily ROM
exercises
 immobilization is followed by quadriceps
strengthening
 Operative
o PCL repair of bony avulsion fractures or reconstruction
 indications
 combined ligamentous injuries 
 PCL + ACL or PLC injuries
 PCL + Grade III MCL or LCL injuries
 isolated Grade II or III injuries with bony
avulsion
 isolated chronic PCL injuries with a
functionally unstable knee
 techniques
 primary repair of bony avulsion fractures
with ORIF
 reconstruction options include
 tibial inlay vs. transtibial
methods 
 single-bundle vs. double-bundle
 autograft vs. allograft
 allograft is typically utilized with multiple
graft choices available
 options include - Achilles, bone-
patellar tendon-bone, hamstring,
and anterior tibialis
 outcomes
 good results achieved with primary repair of
bony avulsions
 primary repair of midsubstance ruptures are
typically not successful
 results of PCL reconstruction are less
successful than with ACL reconstruction
 and residual posterior laxity often exists
 successful reconstruction depends on
addressing concomitant ligament injuries
 no outcome studies clearly support one
reconstruction technique over the other
o high tibial osteotomy
 indications
 chronic PCL deficiency
 techniques
 consider medial opening wedge osteotomy
to treat both varus malalignment and PCL
deficiency   
 when performing a high tibial osteotomy in
a PCL deficient knee, increasing the tibial
slope helps reduce the posterior sag of the
tibia     
 shifts the tibia anterior relative to the
femur preventing posterior tibial
translation
o
MCL Knee Injuries o NSAIDs, rest, therapy o ligament repair vs. reconstruction
 indications  relative indications
 grade I   acute repair in grade III injuries 
 therapy  in the setting of multi-ligament knee
 quad sets, SLRs, and hip injury
adduction above the knee to begin  displaced distal avulsions with
immediately "stener-type" lesion
 cycling and progressive resistance  entrapment of the torn end in the
exercises as tolerated medial compartment
 return to play  sub-acute repair in grade III injuries
 grade I may return to play at 5-7  continued instability despite
days nonoperative treatment
o bracing, NSAIDs, rest, therapy  >10 mm medial sided
 indications opening in full extension
  grades II  reconstruction
 grade III    chronic injury
 if stable to valgus stress in  loss of adequate tissue for repair
full extension  technique
 no associated cruciate  diagnostic arthroscopy recommended for all
injury surgical candidates to rule out associated
 technique injuries
 immobilizer for comfort  o
 hinged knee brace for ambulation
 return to play
 grade II return to play at 2-4 weeks
 grade III return to play at 4-8
weeks
 outcomes
distal MCL injuries have less healing potential than
proximal injuries
LCL Injury of the o limited immobilization, progressive ROM, and functional o isolated LCL repair
Knee rehabilitation  indications
 indications  isolated acute (< 2 weeks) grade III LCL
 isolated grade I or II LCL injury (no injury with avulsed ligament from anatomic
instability at 0°) attachment site (i.e fibula)
 outcomes  outcomes
 return to sport expected in 6-8  some studies have shown failure rates as
weeks high as 40% with repair
 progressive varus/hyperextension o isolated LCL reconstruction
laxity can occur with unrecognized  indications
associated injuries to the PLC  subacute/chronic (> 2 weeks) grade III LCL
injury with persistent varus instability
 complete mid-substance acute grade III
LCL injury with persistent varus instability
 outcomes
 studies shown consistently better outcomes
compared to LCL repair 
 6% failure rate at 3 year followup
 best results noted with anatomic
 reconstruction using a semitendinosus
autograft
o LCL + PLC reconstruction
 indications
 rotatory instability involving LCL/PLC
 posterolateral instability (LCL/PLC) 
 outcomes
 more favorable outcomes when surgeries
are done acutely after injury
o
Posterolateral Corner o knee immobilization in full extension x4 weeks, then 
Injury rehabilitation o PLC repair   
 indications  indications
 grade I PLC injury  isolated acute grade II PLC
 isolated midsubstance grade II avulsion injuries
injury  midsubstance repair have 40%
 technique failure rate following repair
 hinged knee brace locked in  techniques
extension x4 weeks  repair of LCL, popliteus tendon and/or
 followed by progressive functional popliteofibular ligament should be
rehabilitation performed if structures can be anatomically
 quad strengthening reduced to their attachment site
return to sports in 8 weeks  otherwise perform reconstruction
 augment PLC repair with free graft if repair
tenuous
 avulsion fracture of fibular head can be
treated with screws or suture anchors
o PLC hybrid reconstruction and repair
 indications
 grade III midsubstance injuries
 avulsion injuries where repair is not
possible or tissie is poor quality
 techniques   
 goal is to reconstruct LCL and the
 popliteofibular ligament using a free tendon
graft (semitendinosus or achilles)
 fibular-based reconstruction (Larson)   
 soft tissue graft passed through
bone tunnel in fibular head 
 limbs are then crossed to create
figure-of-eight and fixed to lateral
femur to a single tunnel
 trans-tibial double-bundle
reconstruction   
 split achilles tendon is fixed to
isometric point of the femoral
epicondyle
 one tibia-based limb and one fibula-
based limb
 fibula-limb is fixed to the fibular
head with a bone tunnel and
transosseous sutures to reconstruct
the LCL
 tibia-limb is brought through the
posterior tibia to reconstruct the
popliteofibular ligament
 LaPrade anatomic reconstruction   
 two soft tissue grafts
 graft #1 reconstructs the LCL and
PFL
 proximal attachment site at
anatomic femoral LCL
attachment
 through the fibular head
lateral to medial
 docking into the tibial tunnel
posterior to anterior with
graft #2
  graft #2 reconstructs the popliteus
tendon
 proximal attachment site at
the anatomic popliteus
tendon attachment
 docking into the tibial tunnel
posterior to anterior with
graft #1
 rehabilitation
 hinged knee brace, nonweightbearing for 6
weeks
 range of motion protocols differ between
surgeons
 some advocate for passive ROM
immediately 0-90°
 others immobilize for 2 weeks, then
begin motion
 at 6 weeks, begin weightbearing and
closed-chain strenghtening
 return to activities / sports ~ 6 to 9 months
 outcomes
 operative treatment has improved
outcomes compared to nonoperative
treatment
 repair has higher failure rate than
reconstruction
 particularly for midsubstance
injuries, but also for soft tissue
avulsions
 improved outcomes with early treatment
 anatomic reconstruction restores rotatory
stability, but not all varus stability on stress
testing
o PLC reconstruction, +/- ACL reconstruction, +/- PCL
reconstruction, +/- HTO
  indications
 acute and chronic combined ligament
injuries 
 technique
 PLC reconstruction should be performed at
same time or prior to (as staged procedure)
ACL or PCL to prevent early cruciate
failure 
 valgus high tibial osteotomy   
 indicated in patients with varus
mechanical alignment
 failure to correct bony alignment
jeopardizes ACL and PLC
reconstruction success
 rehabilitation
 postoperatively immobilize and
make protected weight bearing for 4
weeks (long leg casts may control leg
external rotation better than brace)
 begin passive ROM at 4 weeks to avoid
arthrofibrosis.
 avoid active hamstring exercises as they
will stress the PLC 
 full active extension is allowed
 outcomes
 reconstructions have less revision
rates and better outcome scores than
ligament repair
 ACL reconstruction + PLC repair
33% achieved IKDC grade A or B
compared to 88% of patients who
underwent ACL + PLC
reconstruction
o
Posteromedial Corner  o PMC reconstruction
Injury o physical therapy  indications
 indications  multiligamentous injuries
 isolated, low-grade medial knee  knee dislocations
injuries that involve the MCL and  tibial-sided sleeve avulsions (sleeve of
posteromedial corner can be tissue encompassing both the MCL and
treated non-operatively posteromedial corner)
 chronic injuries where patients have
developed symptomatic AMRI
o
Proximal Tib-Fib  o surgical soft tissue stabilization vs. open reduction and pinning
Dislocation o closed reduction    vs. arthrodesis vs. fibular head resection   
 indications  indications
 acute dislocations  chronic dislocation with chronic pain and
 technique symptomatic instability
 flex knee 80°- o
110° and apply pressure over the
fibular head opposite to the
direction of dislocation
 post-reduction immobilization
in extension vs. early range of
motion (controversial)
 outcomes
 commonly successful with minimal
disadvantages

Patellar Tendinitis o ice, rest, activity modification, followed by physical 
therapy  o surgical excision and suture repair as needed
 indications  indications
  most cases  Blazina Stage III disease 
 technique  chronic pain and dysfunction not
 physical therapy amendable to conservative treatment 
 stretching of quadriceps  partial tears
and hamstrings  technique
  eccentric exercise program  can be done open or arthroscopic 
 ultrasound treatment may be  resect angiofibroblastic and mucoid
helpful degenerative area 
 taping or Chopat's strap can  follow with bone abrasion at tendon
be used to reduce tension across insertion and suture repair/anchors as
patellar tendon  needed
o cortisone injections  postoperative rehab
 are contraindicated due to risk of patellar  initial immobilization in extension
tendon rupture  progressive range-of-motion and
mobilization exercises as tolerated
 weight bearing as tolerated
 outcomes
 return to activities is achieved by 80% to
90% of athletes
 there may be activity-related aching for 4 to
6 months after surgery
o
Quadriceps  o quadriceps tendon debridement
Tendonitis o activity modification, NSAIDS, and physical therapy  indications
 indications  very rarely required
 mainstay of treatment o
 technique
 rest until pain is improved
 physical therapy starting with
range of motion and progressing to
eccentric exercises
 cortisone injections
contraindicated due to risk of
quadriceps tendon rupture

Iliotibial Band Friction o rest, ice, NSAIDs, corticosteroid injections 
Syndrome  indications  Operative
 initial treatment to reduce pain and o excision of a cyst, burse or lateral synovial recess
swelling  indications
  modalities  failed nonoperative management
 ice  soft-tissue pathology with no signal change
 oral or topical anti-inflammatory in the iliotibial band
medications  techniques
 corticosteroids injection   arthroscopic vs. open
 when conservative  outcome
measures fail  may cause chronic synovial fluid effusion
o physical therapy and training modifications and pain
 indications o elipitical surgical excision of iliotibial band 
 mainstay of treatment that follows  indications
initital treatment phase aimed at  failed nonoperative therapy with chronic
reducing pain and swelling presentation
 modalities  techniques
 therapy  open technique
 stretching of the iliotibial  lateral distal femur incision
band, lateral fascia and  expose posterior portion of the band
gluteal muscles over lateral femoral epicondyle
 deep transverse friction  incise 2 x4 cm ellipse of band tissue
massage o Z plasty of iliotibial band         
 strengthening hip  indications
aBDuctors  only indicated in refractory cases
 proprioception exercises to o
improve neuromuscular
coordination
 training modifications
 change shoes every 300-
500 miles
 avoid sudden increases in
mileage

Patellar Instability o NSAIDS, activity modification, and physical therapy  

 indications o Arthroscopic debridement (removal of loose body) vs Repair with
 mainstay of treatment for first time or without stabilization
patellar dislocator  indications
 without any loose bodies or  displaced osteochondral fractures or loose
 intraarticular damage bodies
 habitual dislocator  may be an indication for operative
 techniques treatment in a first-time dislocator
 short-term immobilization for  techniques
comfort followed by 6 weeks of  arthroscopic vs open removal versus repair
controlled motion of the osteochondral fragment 
 emphasis on strengthening   primary repair with screws or pins if
 closed chain short arc sufficient bone available for fixation 
quadriceps exercises o MPFL repair 
 Quad strengthening  indications
 core and hip strengthening  acute first time dislocation with bony
to improve limb positioning fragment
and balance (hip  techniques
abductors, gluteals, and  direct repair when surgery can be done
abdominals)  within first few days
 patellar stabilizing sleeve or "J"  no clinical studies support this over
brace nonoperative treatment
 consider knee aspiration for tense o MPFL reconstruction with autograft vs allograft         
effusion
 indications
 positive fat
 recurrent instability 
globules indicates fracture
  no significant underlying malalignment
 techniques
 gracilis or semitendinosus commonly used
(stronger than native MPFL)
 femoral origin can be reliably found
radiographically (Schottle point)  
 outcomes
 severe trochlear dysplasia is the most
important predictor of residual
patellofemoral instability after isolated
MPFL reconstruction 
o Fulkerson-type osteotomy (anterior and medial tibial tubercle
transfer)     
  indications
 may be used in addition to MPFL or in
isolation for significant malalignment
 TT-TG >20mm on CT   
 techniques
 anteromedialized displacement of
osteotomy and fixation
 correct TT-TG to 10-15mm (never less than
10mm)
o tibial tubercle distalization
 indications
 patella alta
 techniques
 distal displacement of osteotomy and
fixation
o lateral release
 indications
 isolated release no longer indicated for
instability
 only indicated if there is excessive lateral tilt
or tightness after medialization  
 technique
 arthroscopic 
o trochleoplasty
 indications
 rarely addressed (in the USA) even if
trochlear dysplasia present
 may consider in severe or revision cases 
 techniques
 arthroscopic or open trochlear deepening
procedure
o
Lateral Patellar o NSAIDS, activity modification, and therapy 
Compression  indications arthroscopic lateral release 
Syndrome  mainstay of treatment and should  indications
be done for extensive period of  objective evidence of lateral tilting (neutral
time  or negative tilt)    
 technique  pain refractory to extensive rehabilitation
therapy should emphasize vastus medialis  inability to evert the lateral edge of the
strengthening and closed chain short arc quadriceps exercises  patella
 ideal candidate has no symptoms of
instability
 medial patellar glide of less than one
quadrant
 lateral patellar glide of less than three
quadrants
o patellar realignment surgery 
 Maquet (tubercle anteriorization)
 indicated only for distal pole lesions
 only elevate 1 cm or else risk of skin
necrosis
 Elmslie-Trillat (medialization)
 indicated only for instability with lateral
translation (not isolated lateral tilt)
 avoid if medial patellar facet arthrosis
 Fulkerson alignment surgery (tubercle
anteriorization and medialization) 
 indications (controversial)
 lateral and distal pole lesions 
 increased Q angle
 contraindications
 superior medial arthrosis (scope
before you perform the surgery)
 skeletal immaturity
o
Idiopathic o rest, rehab, and NSAIDS    
Chondromalacia  indications  Operative
Patellae  mainstay of treatment and should o arthroscopic debridement
 be done for a minimum of one year  indications
 technique  Outerbridge grade 2-3 chondromalacia
 NSAIDS are more effective than patellofemoral joint
steroids   techniques
 activity modification  mechanical debridement 
 rehabilitation with emphasis on   radiofrequency debridment
 vastus medialis obiquus o lateral retinacular release
strengthening  indications
 core strengthening  tight lateral retinacular capsule, loose
 closed chain short arc medial capsule and lateral patellar tilt
quadriceps exercises  techniques
 strengthening of hip  open arthrotomy 
external rotators  arthroscopy
o patellar realignment surgery
 indications
 severe symptoms that have failed to
improve with extensive physical therapy
 techniques
 Maquet (anterior tubercle elevation)
 only elevate 1 cm or else risk of skin
necrosis
 Fulkerson (anterior-medialization)
 indications (controversial)
 increased Q angle
 patellar instability
 contraindications
 superior medial
arthrosis (scope before you
perform the surgery)
 skeletal immaturity
 Elmslie-Trillat osteotomy
 MPFL reconstruction
o
Quadriceps Tendon  o primary repair with reattachment to patella
Rupture
 o knee immobilization in brace   indications
 indications  complete rupture with loss of extensor
 partial tear with intact knee mechanism
extensor mechanism o
 patients who cannot tolerate
surgery

Patella Tendon o immobilization in full extension with a progressive o primary repair       
Rupture weight-bearing exercise program  indications
 indications  complete patellar tendon ruptures
 partial tears with intact extensor  ability to approximate tendon at site of
mechanism disruption
 modalities  techniques
 application of a removable knee  end-to-end repair
splint   transosseous tendon repair
 early knee range of motion  suture anchor tendon repair
o tendon reconstruction
 indications
 severely disrupted or degenerative patella
tendon
 techniques
 semitendinosus or gracilis tendon autograft 
 free ends of the tendons are passed
through transosseous hole of the
patella, and then through a
transosseous hole within the tibial
tubercle to make a complete circle
graft.
 other options
 central quadriceps tendon-patellar
bone autograft
 contralateral bone-patellar tendon-
bone autograft
 allograft
 o rehabilitation 
 may weight bear early with protected knee
extension brace
 exercises to optimize range of motion and
minimizes stress on the repair include
 passive extension and active closed chain
flexion (heel slides)   
 prone open chain knee flexion 
o
Articular Cartilage o rest, NSAIDs, physiotherapy, weight loss 
Defects of Knee  indications debridement/chondroplasty vs. reconstruction techniques 
 first line of treatment when  indications
symptoms are mild  failure of nonoperative management 
o viscosupplementatoin, corticosteroid injections,  acute osteochondral fractures resulting in
unloader brace full-thickness loss of cartilage
 indications  technique
 controversial   treatment is individualized, there is no one
may provide symptomatic relief but healing of defect is best technique for all defects
unlikely  decision-making algorithm is based on
several factors
 patient factors
 age
 skeletal maturity
 low vs. high demand
activities
 ability to tolerate extended
rehabilitation
 defect factors
 size of defect
 location
 contained vs. uncontained
 presence or absence of
subchondral bone
 involvement
 basic algorithm (may vary depending on published
data)
 femoral condyle defect
 correct malaligment, ligament
instability, meniscal deficiency
 measure size 
 < 4 cm2 = microfracture or
osteochondral autograft
transfer (pallative if older/low
demand)
 > 4 cm2 = osteochondral
allograft transplantation or
autologous chondrocyte
implantation
 patellofemoral defect
 address patellofemoral maltracking
and malalignment
 measure size 
 < 4 cm2 = microfracture
or osteochondral autograft
transfer
 > 4 cm2 =  autologous
chondrocyte
implantation (microfracture if
older/low demand)
o
o
Osteonecrosis of the  o diagnostic arthroscopy
Knee o NSAIDs, limited weightbearing, quadriceps  indications
strengthening, activity modification  remove small, unstable fragments from the
 indications joint
 first-line of treatment o core decompression
 outcomes  indications
  favorable, but less so than  extra-articular lesions
nonoperative management for o osteochondral allograft
SONK  indications
  large symptomatic lesions in younger
patients that failed nonoperative
management
o total knee arthroplasty (TKA) 
 indications
 large area of involvement
 collapse
 osteonecrosis in multiple compartments
o
Spontaneous  o arthroplasty
Osteonecrosis of the o NSAIDs, narcotics, protected weight bearing  indications
Knee (SONK)  indications  when symptoms fail to respond to
 mainstay of treatment as most conservative treatment
cases resolve  outcomes
 technique  successful results reported with TKA (larger
 physical therapy directed at lesions or bone collapse) and UKA (smaller
quadriceps strengthening lesions) when properly indicated     
 outcomes o high tibial osteotomy
 initial conservative measure and  indications
has shown good results  when angular malalignment present
 o
Osteochondritis o restricted weight bearing and bracing      o diagnostic arthroscopy
Dissecans  indications  indications
 stable lesions in children with open  impending physeal closure
 clinical signs of instability
physes     expanding lesions on plain films
 asymptomatic lesions in adults  failed non-operative management
 outcomes o subchondral drilling with K-wire or drill
 50-75% will heal without
 indications
fragmentation
 stable lesion seen on arthroscopy
 performed either transchondral or
 retrograde
 outcomes
 leads to formation of fibrocartilagenous
tissue
 improved outcomes in skeletally immature
patients
o fixation of unstable lesion
 indications
 unstable lesion seen on arthroscopy or MRI
>2cm in size
 outcomes
 85% healing rates in juvenile OCD
o chondral resurfacing
 indications
 large lesions, >2cm x 2cm
o knee arthroplasty
 indications
 patients > 60 years
o
Osgood Schlatter's o NSAIDS, rest, ice, activity modification, o ossicle excision
Disease (Tibial strapping/sleeves to decrease tension on the  indications 
Tubercle Apophysitis) apophysitis and quadriceps stretching  refractory cases (10% of patients) 
 indications  in skeletally mature patients with persistent
 first line of treatment symptoms
 outcomes o
 90% of patients have complete
resolution
o cast immobilization x 6 weeks
 indications
 severe symptoms not responding
to simple conservative
management above

Sinding-Larsen-  o debridement of damaged tissue/stimulation of healing response

Johansson Syndrome
 o activity modifications, NSAIDS, physical therapy  in some cases refractory to nonoperative treatment
 indications o
 mainstay of treatment
 usually a self limiting process


Snapping Hip (Coxa o often internal and external snapping are painless and require 
Saltans) no treatment  Operative
o activity modification o excision of greater trochanteric bursa with Z-plasty of iliotibial
 indications band
 acute onset (<6 months) of painful  indications
internal or external snapping hip  painful external snapping hip that has
o physical therapy, injection of corticosteroid failed nonoperative management
 indications  snapping after total hip replacement
 persistent, painful snapping o release of iliopsoas tendon     
interfering with activities of daily  indications
living  painful internal snapping hip that has failed
of nonoperative management
o hip arthroscopy with removal of loose bodies or labral
debridement/repair
 indications
 intra-articular snapping hip that has failed
nonoperative management and has MRI
confirmation of 
 loose bodies
 labral tear
o
Hip Labral Tear o rest, NSAIDS, physical therapy, steroid injections 
 indications o arthroscopic labral debridement
 initial treatment of choice for all  indications
patients with labral tears  symptoms that have failed to improve with
 outcomes nonoperative modalities
 no long-term follow-up data on  labral tear not amenable to repair
conservative management
   technique
 remove any unstable portions of the labrum
and associated synovitis
 underlying hip pathology (e.g. FAI) should
also be addressed at time of surgery
 post-operative care
 limited weight-bearing x4 weeks
 flexion and abduction are limited for
4 to 6 weeks
 outcomes
 70-85% experience short-term relief of
symptoms following arthroscopic
debridement
 long-term follow-up data not available
o arthroscopic labral repair 
 indications
 symptoms that have failed to improve with
nonoperative modalities
 full-thickness tears at the labral-chondral
junction
 outcomes
 unknown at this time
o
Femoroacetabular  o arthroscopic osteoplasty 
Impingement o activity modification, PT, NSAIDs   indications
 indications  symptomatic patient with mechanical
 minimally symptomatic patient symptoms
 no mechanical symptoms  failure of non-operative measures
 modalities  non-arthritic
 period of rest or activity  outcomes
modification followed by physical  recent literature supports arthroscopy
therapy to address kinetic chain shows equivalent results to open hip
abnormalities surgery
 NSAIDs  decreased functional and symptomatic
outcomes in patients with evidence of hip
 osteoarthritis (Tonnis grade 1 or
greater) 
o open surgical hip dislocation and osteoplasty
 indications
 previous gold standard for patients with
clinical signs and structural evidence of
impingement
 preserved articular cartilage, correctable
deformity, reasonable expectations
 significant femoral deformity (residual
SCFE or Perthes)
o periacetabular osteotomy 
 indications
 structural deformity of acetabulum with
significant retroversion
o hip arthroplasty 
 indications
 arthritic and end-stage hip degeneration
 controversial regarding hip resurfacing
versus total hip arthroplasty
o
 o tendon repair 
o rest, ice, NSAIDS, protected weightbearing for 4  indications
weeks followed by stretching and strengthening  proximal avulsion ruptures 
 indications  partial avulsion that has failed nonoperative
 most hamstring injuries management for 6 months (persistent
 all single tendon tears
Hamstring Injuries symptoms) 
 2 tendon tears with < 2 cm
 2 tendons with at least > 2 cm retraction in
retraction
young, active patients
 rupture at myotendinous junction
 3 tendon tears
 less active patients and those with
 outcomes
significant medical comorbidities
 80% return to preinjury level/sports at 6
 outcomes
months
 take up to 6 weeks to heal 
  only return when strength is 90%  high level of complications with surgery, up
of contralateral side to avoid to 23% in some studies
further injury  higher complication rate with repair
o PRP injection of chronic cases compared to acute
 indications (< 6 weeks)
 acute hamstring strains in high o ORIF 
level athletes  indications
 outcomes  bony avulsions with > 2
 some low level studies have
shown earlier return to play by 3-5 cm displacement 
days in NFL players  chronic symptomatic bony avulsions
 outcomes

 union rates vary across studies 
o
Exertional  o two incision fasciotomy
Compartment o activity modification  indications
Syndrome  indications  refractory cases
 rarely effective  technique
o anti-inflammatories  two incision approach
o attempt these treatments for 3 months prior to operating  lateral incision
  release anterior and lateral
compartments
 12-15 cm above lateral
malleolus
 identify and
protect superficial peroneal
nerve
 may see fascial hernia
 medial incision
 used to release posterior
compartments
 perform if needed based on
measurements
 release  at middle of tibia at
posterior border
  endoscopic
 smaller incisions, similar
complications
 outcomes
 not a "home run" procedure because
symptoms are often multi-variable
 no studies directly comparing operative to
non-opertative treatment options
 surgery is successful in >80% of cases for
the anterior compartment
 deep posterior compartment
success is lower (around 60%)
o
Popliteal Artery  o vascular bypass with saphenous vein vs endarterectomy
Entrapment o activity modification and observation  indications
Syndrome  indications  if damage to the popliteal artery or vein
 mild symptoms with rigorous  most patients eventually require surgery
exercise only  technique
  can perform posterior or medial approach
to popliteal fossa
 posterior approach provides
improved exposure
 medial approach used more when
bypass is indicated
 structures released depend on the type of
entrapment
o
Femoral Neck Stress o non-weight bearing, crutches and activity restriction 
Fractures  indications o ORIF with percutaneous screw fixation
  compression side stress fractures  indications
with fatigue line <50% femoral  tension side stress fractures 
neck width     compression side stress fractures with
 fatigue line >50% femoral neck width
 progression of compression side stress
 fractures
 technique
 use three 6.5mm or 7.0mm cannulated
screws
 postoperative weightbearing as tolerated
o
Femoral Shaft Stress o rest, activity modification, protected weight bearing o locked intramedullary reconstruction nail 
Fractures   indications  indications
 most femoral shaft stress fractures  prophylactic fixation
 technique  patients with low bone mass
 restrict weight bearing until the  patients >60 years old
fracture heals  fracture completion or displacement
 incorporate cross-training into  technique
running programs  reamed insertion is preferred
o
Tibial Shaft Stress o activity restriction with protected weightbearing      o intramedullary tibial nailing 
Fractures  indications
 indications   if "dreaded black line" is present, especially
 most cases if it violates the anterior cortex
 technique  fractures of anterior cortex of tibia
 avoids NSAIDs (slows bone have highest likelihood of delayed
healing) healing or non-union
 consider bone stimulator o

Medial Clavicle o observation o closed reduction under anesthesia

Physeal Fracture  indications   indications
 most asymptomatic injuries  acute posterior displacement with airway,
 will remodel and do not esophageal, or neurovascular compromise
require intervention as the  contraindications
periosteal sleeve is  late presenting posterior
intact  dislocations
 anterior displacement  closed reduction not
 have good functional attempted as medial clavicle
may be adherent to vascular
 results treated structures in the
nonoperatively mediastinum
 posterior displacement o open reduction internal fixation
if no injury to mediastinal structures  indications
 failure of closed reduction with continued
symptoms
 chronic symptomatic posterior dislocations
 postreduction management
 obtain CT to confirm stability
o
Clavicle Shaft o open reduction internal fixation
Fracture - Pediatric o observation / care with lifting  indications
 indications  controversial: adolescent fractures with
 newborn birth fractues significant shortening(>2cm)
 outcomes  absolute
 union occurs at approx 1 wk  open fxs
o sling or shoulder immobilizer with progressive motion  displaced fracture with soft-tissue at
 indications risk from tenting
 <12 years of age  subclavian artery or vein injury
 due to high remodeling o
potential almost all
fractures in this age group
are treated nonoperatively
 outcomes
 nonunion/malunion rare in <12 yo
 may have prominent area of
callous which generally becomes
less apparent over 6-12 mo

Distal Clavicle 
Physeal Fractures o sling management  o surgical reduction
 indications  absolute indications (rare)
 indicated in most cases, especially  open fractures
if periosteum is intact   significant skin compromise
 displaced intra-articular extension
  a new clavicle will form  a/w neurovascular injuries requiring surgery
within the intact periosteal  relative
sleeve resulting in a Y  severely displaced fractures in older
shaped clavicle patients with nearly closed physis
 the displaced clavicle will  displaced and entrapped fragment in
typically reabsorb with time trapezius
and growth   floating shoulder injuries
 some Type III fractures in patients
approaching skeletal maturity
 types IV, V, and VI may need open
reduction with repair of periosteal sleeve
o
Proximal Humerus o closed reduction +/- fixation
Fracture - Pediatric o immobilization      indications
 indications  unacceptable alignment for non-operative
 acceptable alignment for non- management as described above
operative management o open reduction internal fixation
 <10 years old  = any  indications 
degree of angulation  unable to obtain acceptable reduction due
 10-12 years old  = up to 60- to soft tissue interposition
75° of angulation  long head of biceps tendon (most
 >12 years old = up to 45° common)
of angulation or 2/3  joint capsule
displacement  infolded periosteum
 technique  deltoid muscle
 immobilization modalities  open fractures 
 sling +/- swathe  fractures associated with vascular injuries
 shoulder immobilizer  intra-articular displacement
 coaptation splint o

Humeral Shaft  o open reduction internal fixation

Fracture - Pediatric o immobilization in splint or brace  indications
 indications  open fractures
 utilized for almost all pediatric  multiply injured patient 
 humeral shaft fractures (if not  ipsilateral forearm fractures
pathologic) due to remodeling  "floating elbow"
potential  associated shoulder injury
 acceptable alignment  unacceptable alignment
 younger children  techniques
 < 35-45 deg  flexible intramedullary nail fixation 
angulation  anterior, anterolateral or posterior approach
 older children with 3.5mm or 4.5mm plate fixation
 < 20 deg o
varus/valgus
 < 20 deg
procurvatum
 <15 deg rotation
malalignment
 < 2cm shortening
 techniques
 sling and swathe or cuff and collar
in young children
 Coaptation splint or hanging arm
cast
 Sarmiento functional brace in older
children/adolescents 
 ROM exercises can be initiated in
2-3 weeks once pain is controlled

Distal Humerus  o closed reduction and pinning 

Physeal Separation - o posterior long arm splint then long arm casting x 2-3  indications
Pediatric weeks  displaced fractures (most)
 indications  pinning is necessary to ensure
 limited role because most fractures adequate reduction, which may be
are displaced lost with casting alone once the
 nondisplaced fractures swelling subsides
 late presenting fractures  technique
 treat nonoperatively  combined with elbow arthrogram to
initially 
  deformity will determine direction of initial displacement
persist/develop, requiring and adequate reduction 
osteotomy in future o

Supracondylar  o closed reduction and percutanous pinning (CRPP)          
Fracture - Pediatric  o long arm casting with less than 90° of elbow flexion
 indications   indications  
 warm perfused hand without neuro  fracture pattern 
deficits and  type II and III supracondylar
  Type I (non-displaced) fractures
fractures   flexion type
  Type II fractures that meet  medial column collapse
the following criteria   time to CRPP dictated by neurovascular status 
 anterior humeral  non-urgent (can wait overnight)
line intersects the  indications 
capitellum  warm perfused hand without
 minimal swelling neuro deficits
present  some argue can treat
 no medial an isolated AIN injury
comminution in non-urgent fashion
 technique   technique 
 typically used for 3 weeks   splint in 30-40° elbow
 repeat radiographs at 1 week to flexion, admit overnight for
assess for interval displacement observation and elevation for
 elective surgery
 urgent  (same day - do not wait
overnight)   
 indications 
 pulseless, well-perfused
hand
 sensory nerve deficits
 excessive swelling
 "brachialis sign" 
 ecchymosis,
 dimpling/puckering
antecubital fossa,
palpable
subcutaneous bone
fragment 
 indicates
proximal
fragment
buttonholed
through
brachialis 
 implies more serious
injury, higher
likelihood of arterial
injury, significant
swelling, more
difficult closed
reduction
 "floating elbow"
 ipsilateral
supracondylar
humerus and
forearm/wrist
fractures warrant
timely pinning of both
fractures to decrease
the risk
of compartment synd
rome     
 technique 
 check vascular status after
reduction 
 if evidence of good
distal perfusion admit
 for 48 hours of
observation 
 if not well perfused
perform vascular
exploration
 emergent (within hours)
 indications 
 pulseless, poorly perfused
hand   
 technique
 check vascular status after
reduction
 if well perfused admit
and observe for 48
hours
 if not well perfused
perform vascular
exploration
o emergent vascular exploration and CRPP
 indications 
 pulseless white hand (pale, cool, no
doppler) following CRPP
 pulsatile and perfused hand that loses
pulse following CRPP
 technique 
 remove K-wires and reassess vascular
status   
 open exploration and reduction if vascular
status does not improve
o open reduction, percutaneous pinning, +/- vascular exploration
 indications 
 open fracture
 failed closed reduction 
 more frequently required with flexion
 type fractures (compared to
extension type)
 pulseless white OR pink hand that is unable
to be reduced or there remains a gap 
 gap might represent entrapped
vascular structure
o
Medial Epicondylar  o open reduction internal fixation
Fractures - Pediatric o immobilization (1-3 weeks) in a long arm cast with elbow  indications 
flexed to 90 degrees  absolute 
 indications   displaced fx with entrapment of
 controversial medial epicondyle fragment in
 < 5mm displacement joint         
  amount of true displacement  extension to the articular surface
difficult to determine on plain with medial condyle involvement
radiographs (articular surface)
 outcomes   open fracture
 lower rate of osseous union rate  relative 
compared to surgically treated  ulnar nerve dysfunction
patients  > 2-15mm displacement, also
 radiographic nonunion (or fibrous controversial 
union) often asymptomatic  >2-5 mm in valgus stress athletes
 such as throwers or gymnasts 
 associated elbow dislocation
o
Lateral Condyle  o CRPP + 3-6 wks in above elbow cast
Fracture - Pediatric  o long arm casting x 4-6wks  indications
 indications   fractures with 2 -  4 mm of displacement
 only if < 2 mm displacement in all have intact articular cartilage and can be
views treated with CRPP
 medial cartilaginous hinge must o open reduction and fixation + 3-6 wks in above elbow cast
remain intact  indications
 technique   > 4mm of displacement
 cast with elbow at approx 90  open reduction (rather than closed)
 degrees as long as swelling is mild necessary to align the joint surface
 weekly follow up and radiographs  joint incongruity 
every week x first 3 weeks,  fracture non-union
including internal oblique view o supracondylar osteotomy
 occasionally > 6 weeks of casting  indications 
is needed  deformity correction in late-presenting
 cubitus valgus - rarely needed
o
Olecranon Fractures -  o ORIF   
Pediatric o NSAIDS, rest, immobilization with avoidance of elbow  indications 
resistance exercises  displaced fractures
 indications   unstable fractures with loss of posterior
 stress fractures in repetitive motion periosteum
athletes  comminution
 apophysitis  techniques 
 outcomes  tension band wiring 
 monitor until there is clinical  AO technique with axial K-wires
improvement  congruent articular surface
 convert to casting if needed  consider early range of motion post-
o long arm splint or casting  operatively
 indications   high rate of removal of hardware
 minimally displaced fractures  tension band suturing 
 duration  use absorbable sutures (e.g.
 3-4 weeks total Number 1 polydioxanone (PDS)
 repeat imaging at 7 days to ensure suture or fiberwire)
no significant displacement  may combine with oblique cortical
 lag screw with PDS with
metaphyseal fractures
 plate and screws  
 considered with comminuted
fractures with partially fused
ossification centers
 axial screw +/- tension wiring
o
Radial Head and Neck  o closed percutaneous reduction 
Fractures - Pediatric o immobilization alone  indications 
 indications   > 30° of residual angulation following
 <30 degrees of angulation closed reduction 
 <3mm translation  3-4 mm of translation
 technique   < 45° of pronation and supination
 immobilize in long arm cast or  outcomes
splint without reduction  improved outcomes with younger patients,
 follow-up  lesser degrees of angulation, and isolated
 7 days of immobilization followed radial neck fractures
by early range of motion o open reduction
o closed reduction and immobilization  indications 
 indications  fracture that cannot be adequately reduced
 >30 degrees of angulation to <45 degrees angulation with closed or
 closed reduction followed by percutaneous methods 
immobilization in long arm cast or  outcomes
splint if an adequate reduction is  open reduction has been associated with a
achieved greater loss of motion, increased rates of
 osteonecrosis and synostosis compared
with closed reduction  (though this is
controversial as higher rates of open
reduction are also seen with worse
fractures)
o
Elbow Dislocation -  o open reduction 
Pediatric o closed reduction, brief immobilization with early range  indications 
of motion     open dislocation
 indications   incarcerated medial epicondyle or coronoid
 dislocation that remains stable process in the joint
following reduction  failure to obtain or maintain an adequate
 indicated in the majority of closed reduction
cases  significant joint instability (rare)
 reduction technique (see below)  o
 should be addressed promptly as
 reduction should not be delayed 
 brief immobilization 
 immobilization should be
minimized to 1- 2 weeks to
minimize risk of stiffness 
 early therapy 
 encourage early active range of
motion

Monteggia Fracture -  o plating of ulna + reduction of radial head ± annular ligament
Pediatric  o closed reduction of ulna and radial head dislocation and repair/reconstruction     
long arm casting  indications 
 indications   Bado Types I-III with
 Bado Types I-III with  radial head is not stable following
 radial head is stable following reduction reduction
 length stable ulnar fracture pattern  ulnar length is not stable (unable to
 reduction technique     maintain ulnar length)
 reduction technique uses traction   acute Bado Type IV 
 radial head will reduce  open fractures
spontaneously with  older patients ≥ 10y if closed reduction is
reduction of the ulna and not stable
restoration of ulnar length  technique 
 for Type I, elbow flexion is  annular ligament reconstruction almost
the main reduction never required for acute fractures
maneuver  open reduction of radial head through a
 immobilization  lateral approach if needed in chronic (>2-3
 Type I  110° of flexion and full weeks old) Monteggia fractures where
supination to tighten interosseous radial head still retains concave
membrane and relax biceps structure 
tendon   symptomatic individuals (pain, loss of
 Type II fulll extension.    forearm motion, progressive valgus
 Type III full extension and valgus deformity) who had delayed treatment or
mold missed diagnosis

 o ORIF similar to adult treatment 
 indications 
 closed physes
o
Both Bone Forearm o percutaneous vs open reduction and intramedullary
Fracture - Pediatric o closed reduction and immobilization nailing 
indications  indications 
most pediatric forearm fractures unacceptable alignment following closed
can be treated without surgery when an adequate reduction is reduction 
maintained    angulation >15°, rotation >45° in
greenstick injuries children <10y
plastic deformation if over 20 angulation >10°, rotation >30° in
degrees children >10y
bayonet apposition ok if <10 years bayonet apposition in children older
and growth remains than 10 years
modalities  both bone forearm fractures in
closed reduction with analgesia children >13y 
and casting or splinting  relative indications
options for analgesia vary highly displaced fractures
from local block, regional block, conscious sedation, and generalo open reduction and internal fixation 
anesthesia indications 
unacceptable alignment following closed
reduction 
angulation >15° and rotation >45° in
children <10y 
angulation >10° and rotation >30° in
children >10y
bayonet apposition in children older
than 10 years
open fractures
refractures
both bone forearm fractures in children
>13y (nearing skeletal maturity) 
relative indications
 highly displaced fractures
highly comminuted or segmental fractures
o
Distal Radius  o closed reduction and percutaneous pinning (CRPP)
Fractures - Pediatric o immobilization in short arm cast for 2-3 weeks without  indications 
reduction  unstable patterns unable to reduce initially,
 indications  or with loss of reduction in cast at follow-up
 unicortical or bicortical  Salter-Harris I or II fractures in the setting of
fracture with < 10 deg of neurovascular (NV) compromise 
angulation  CRPP reduces need for tight
 torus/buckle fracture casting in setting with increased
 ongoing shift towards concern for compartment syndrome
treating buckle fractures  fractures unable to reduce in emergency
with pre-fabricated department (ED) but successfully closed
removable wrist splint, no reduced under anesthesia in the operating
cast, and limited follow-up room (OR) may be pinned for added
o closed reduction under conscious sedation followed by stability
casting o open reduction and internal fixation
 indications   indications 
 > 10-20 degrees of angulation  displaced Salter-Harris III and IV
 Salter-Harris I with unacceptable fractures of the distal radial
alignment physis/epiphysis unable to be closed
 Salter-Harris II with unacceptable reduced
alignment  irreducible fracture closed
 technique (see below)   often periosteum or pronator
 reduction technique determined by quadratus block to reduction
fracture pattern o
 acceptable criteria (see table above) 
 acceptable angulations are
controversial in the orthopedic
community
 accepted angulation is defined on
a case by case basis depending
on 
 the age of the patient
  location of the fracture
 type of deformity
(angulation, rotation,
bayonetting)
 outcomes 
 short-arm (SAC) vs long-arm
casting (LAC) 
 good SAC (proper cast
index = sagital/coronal
widths close to 0.7 for good
cast) considered equal to
LAC for distal radius
fractures
 conservative
treatment though
often utilizes LAC to
reduce impact of
variable cast
technique/quality
 no increased risk of loss of
reduction with (good) short
arm vs. long arm
casting 
 cast index 
 loss of reduction is
associated with poor cast
index 
 follow-up 
 all forearm fractures serial
radiographs should be taken every
1 to 2 weeks initially to ensure
reduction is maintained.
 if concern for physeal injury, must
follow child at least until growth
 seen on radiographs to confirm no
growth arrest

Galeazzi Fracture -  o open reduction internal fixation +/- DRUJ pinning
Pediatric o closed reduction with long arm casting  indications 
 indications   unable to obtain anatomic closed reduction
 first-line of treatment in children  irreducible DRUJ due to interposed tendon
 92% of adults experience or periosteum
poor outcomes with non-  technique
operative management  radial fixation can be done with volar plate
 reduction  or flexible IMN (see below)
 requires anatomic reduction of o ORIF, soft tissue reconstruction of DRUJ and TFCC, +/-
both the radius fracture and the corrective osteotomy
DRUJ  indications 
 supination is required for reduction  chronic DRUJ instability (a rare
if there is dorsal subluxation of the consequence of a missed injury)
ulna o corrective osteotomy with soft tissue reconstruction of DRUJ
 pronation is required for reduction and TFCC
if there is volar subluxation of the  indications 
ulna  DRUJ subluxation is caused by a radial
 immobilization  malunion 
 place in above elbow cast in  a corrective osteotomy is also
supination  required in addition to
 outcomes  reconstruction, otherwise a soft
 good to excellent with proper tissue reconstruction of the DRUJ
reduction of the radius and alone will fail
concomitant DRUJ reduction, even o
in cases where the DRUJ injury
was not initially recognized

Pelvis Fractures -  o ORIF
Pediatric o protected weight bearing followed by therapy  indications 
 indications   pelvic ring
 pelvic ring  type I avulsion injuries with > 2-3 cm
 dislocations of symphysis displacement
 and SI joint have  type II iliac wing fractures with > 2-3
a potential for periosteal cm displacement
healing  type III pelvic ring with displaced
 Type I Avulsion Injuries acetabular fractures > 2mm
with < 2 cm displacement  type IV pelvic ring with instability
 Type II Iliac Wing and > 2 cm pelvic ring displacement
Fractures with < 2 cm  acetabulum
displacement  comminuted acetabular fracture
 Type III pelvic ring fractures when traction does not improve the
without segmental position of fragments
instability  joint displacement >2mm
 acetabulum  joint incongruity 
 minimally displaced  intra-articular fragments
fractures as these are  joint instability (persistent medial
relatively stable subluxation or posterior subluxation)
 need close follow-up until  central fracture dislocation
skeletal maturity to detect  open fractures
premature triradiate closure o External fixation
 technique  indications 
 for types I and II   hemodynamic instability
 protected weight bearing  increased pelvic volume
for 2-4 weeks o Pelvic arteriography
 stretching and  indications
strengthening 4-8 weeks  continued hemodynamic instability
 return to sport and activity  evidence of pelvic hemorrhage
after 8 weeks when o
asymptomatic
 type III 
 weight bearing as tolerated
for 6 weeks
o bedrest
 indications 
 Type IV pelvic ring with instability
AND < 2 cm pelvic ring
displacement 
 
Proximal Femur  o emergent ORIF with capsulotomy (or joint aspiration)
Fractures - Pediatric o closed reduction and spica abduction casting   indications
 indications (rarely indicated)  open hip fractures (rare)
 Type I without epiphyseal  vessel injury where large vessel repair is
dislocation, II, III, IV IF required (rare)
nondisplaced/minimally displaced  concomitant hip or epiphyseal dislocations
AND < 4 years old (especially type I)
 evaluate type I fractures for  fractures with significant displacement 
non-accidental trauma if  some data suggests this may
young (< 2-3 years old) decrease the rate of AVN
 o closed reduction percutaneous pinning (CRPP) 
 indications 
 type I (without epiphyseal dislocation), II, III
if displaced and/or > 4 years old
 fixation
 smooth pins may be adequate in young
patients if postoperative spica casting
performed
 cannulated screws in older patients and
adolescents
 postop 
 fracture brace or spica cast if there is
concern that the long lever arm of the leg
could contribute to loss of fixation of the
fracture
o ORIF with pin/screw fixation 
 indications
 type I II, III if unable to achieve closed
anatomic reduction
 postop 
 consider fracture brace or spica cast if
concern for stability of fracture
o ORIF with sliding hip screw (DHS) 
  indications 
 type IV if displaced or > 4 years old
o
Femoral Shaft  o flexible intramedullary nails 
Fractures - Pediatric o Pavlik harness  indications 
 indications   most length stable fracture patterns
 children < 6 months old in children 5-11 years old weighing < 49kg
 any fracture pattern (100 lbs)
o spica casting    o submuscular bridge plate fixation 
 indications   indications 
 children 0-5 years old  unstable fractures in children > 5 years old
 relatively contraindicated with
and > 49kg (100lbs)     
polytrauma, open fractures and
 very proximal or very distal fractures
shortening > 2-3 cm
 severe comminution
o traction + delayed spica casting
o antegrade rigid intramedullary nail fixation 
 indications 
 indications 
 younger patients with significant
 in patients > 11 years old or approaching
shortening 
skeletal maturity
 rarely utilized
 unstable fractures

 fractures in patients weighing > 49kg (100
lbs)
o external fixation   
 indications 
 damage control orthopedics in
a polytrauma patient   
 open fractures 
 associated vascular injuries requiring
revascularization
 segmental or significantly comminuted
fractures
o
  o closed reduction and percutaneous fixation followed by
 7 o long leg casting    casting   
Distal Femoral  indications   indications 
Physeal Fractures -  nondisplaced fractures  majority of cases
Pediatric  treated for 4-6 weeks  displaced Salter-Harris I or II fractures
 close clinical follow up is mandatory   displaced fractures successfully reduced
 with closed methods typically should still be
secured with fixation as fracture pattern is
unstable
 some Salter-Harris III or IV injuries if
anatomic reduction is achieved
 postoperatively follow closely to monitor for
deformity
o ORIF
 indications 
 Salter-Harris III and IV with weight-bearing
articular involvement 
 irreducible SHI and SHII fractures 
 irreducible type II fractures are most
often due to interposed periosteum
on the tension side of fracture
o
Tibial Eminence  o ORIF vs. all-arthroscopic fixation
Fracture o closed reduction, aspiration of hemarthrosis,  indications
immobilization in full extension  Type III or Type II fractures that cannot be
 indications reduced
 non-displaced type I and reducible  type II fractures may fail to reduce
type II fractures due to the entrapped medial
 reduction technique meniscus, entrapped intermeniscal
 see techniques below  ligament, or the pull of the lateral
 immobilization meniscus attachment
 cast in extension for 3-4 weeks   block to extension
 patients get extremely stiff o
with prolonged
immobilization
 allows for gradual rehab
program 
 
Tibial Tubercle  o open reduction internal fixation with arthrotomy +/- arthroscopy,
Fracture  o long leg cast in extension for 6 weeks +/- soft tissue repair   
 indications   indications
 Type I injuries or those with  Type II-IV fractures - need to visualize joint
minimal displacement (< 2 mm) surface for perfect reduction and evaluate
 acceptable displacement after for intra-articular pathology
closed reduction/cast application  soft tissue repair for Type V (periosteal
 sleeve) fracture
o
Patella Sleeve  o open reduction and internal fixation 
Fracture o cylinder cast for 6 weeks   indications 
 indications   > 2-3mm displacement
 nondisplaced fractures with intact  > 2-3mm articular step-off
extensor mechanism   disrupted extensor mechanism
 rare (most require ORIF) o

Proximal Tibia  o CRPP
Epiphyseal Fractures o immobilization in long leg cast  indications 
- Pediatric  indications   unstable Salter-Harris type I and type II
 non-displaced (< 2mm) fractures  fractures
 stable Salter-Harris type I and type  redisplacement following closed treatment
II fractures o ORIF   
 techniques  indications 
 reduce with traction and gentle  irreducible fractures
flexion  usually due to diaphyseal periosteal
 cast in slight flexion for 6 weeks flap blocking reduction
 outcomes   displaced (> 2mm) Salter-Harris type III and
 redisplacement is common without type IV fractures 
fixation  vascular injury
 o
Proximal Tibia  o open reduction
Metaphyseal o long leg cast in extension with varus mold  indications (rare) 
Fractures - Pediatric   indications  inability to adequately reduce a displaced
  nondisplaced fractures fracture
 technique  secondary to soft tissue interposition
 place cast with varus mold (aim for  modalities 
slight overcorrection)  limited open dissection to remove
 casts are maintained for 4-6 weeks interposed soft tissue
with serial radiographs  casting in near full extension, with or
 weight bearing may be allowed without supplemental k-wire fixation
after 2-3 weeks. o
o reduction, long leg cast in extension with varus mold
 indications
 displaced fractures
 technique
 reduction usually done under
conscious sedation
 casting is same as above

Tibial Shaft Fractures  o external fixation
- Pediatric o long leg casting  indications  
 indications   open or closed fractures with extensive soft
 almost all Toddler's fracture      tissue injury, length unstable fractures, or
 Greenstick fractures poly-trauma patients
 followup  o flexible intramedullary nails
 follow up x-rays in 2 weeks to  indications
evaluate for callus in order to  open or closed fractures in skeletally
confirm the diagnosis in equivocal immature patients
cases  multiple long bone fractures or floating knee
o percutaneous pinning
o closed reduction and long leg casting   
 indications
 indications   noncomminuted, unstable oblique fractures
 most traumatic fractures   may be used with casting
 displaced with acceptable o rigid intramedullary nailing 
reduction 
 indications
 50% translation  open or closed tibial shaft fractures in
 < 1 cm of patients at or near skeletal maturity
shortening o plate fixation
  < 5-10 degrees of  indications 
angulation in the  open or closed fractures with physeal or
sagittal and coronal articular extension
planes  length unstable fractures
 mold cast to decrease likelihood of  nonunions or malunions
fracture displacement  o
 complete fractures with intact
fibula tend to fall into varus
 complete fractures with fracture
fibula tend to fall into valgus and
recurvatum
 followup 
 serial radiographs are performed
to monitor for developing deformity
 serial followup if physeal extension
to monitor for growth disturbance

Ankle Fractures -  o CRPP 
Pediatric  o removable walking boot vs. NWB short-leg cast for 4  indications
weeks   distal fibula 
 indications  displaced (> 2mm) SH I or II fracture
 distal fibula with unacceptable closed
 non-displaced (< reduction and > 2 years of growth
2mm) isolated distal fibular remaining
fracture  distal tibia
o closed reduction and NWB cast for 6 weeks  displaced SH I or
 indications II fracture with unacceptable closed
 distal fibula reduction (varus, > 10° valgus, >
 displaced (> 2mm) SH I or 10° recurvatum/procurvatum, >
II fracture with acceptable 3mm physeal widening) and > 2
closed reduction  years of growth remaining
 distal tibia  displaced SH III or IV fracture with <
 displaced SH I or II fracture 2mm displacement following closed
with acceptable closed reduction
reduction (no varus, < 10° o ORIF
 valgus, < 10°  indications 
recurvatum/procurvatum, <  distal fibula 
3mm physeal widening)   displaced (> 2mm) isolated distal
 fibula fracture (usually SH I or II)
with unacceptable closed
reduction and < 2 years of growth
remaining
 distal tibia 
 displaced SH I or
II fracture with unacceptable closed
reduction (varus, > 10° valgus, >
10° recurvatum/procurvatum, >
3mm physeal widening) and < 2
years of growth remaining
 displaced SH III or IV fracture with >
2mm displacement following closed
reduction
o
Tillaux Fractures  o CRPP vs. ORIF
o closed reduction and casting  indications 
 indications   > 2mm displacement remains after
  < 2mm displacement following reduction attempt 
closed reduction (rare)  o

Triplane Fractures   o CRPP vs. ORIF
o closed reduction and casting  indications 
 indications   > 2mm displacement
 < 2mm displacement o
 techniques 
 ideal for 2-part fractures (difficult to
achieve reduction of 3-part or 4-
part fractures)
 reduction maneuvers 
 reduce fibula fracture prior
to attempting reduction of
 tibial fracture
 for lateral triplane fractures,
reduce with internal
rotation 
 for medial triplane
fractures, reduce
with eversion
 obtain post-reduction CT to assess
reduction
 long leg cast initially for 3-4 weeks
to control rotational component of
injury 
 follow early with
radiographs to assess for
displacement
 immobilize an additional 2-4 weeks
in a short leg cast or walking boot
(to initiate ankle ROM)

Sprengel's Deformity  o observation o surgical correction
   indications  indications
 no severe cosmetic concerns or  severe cosmetic concerns or functional
loss of shoulder function deformities (abduction < 110-120 degrees)
 best to perform surgery from 3 to 8 yrs of
age
 risk of nerve impairment after the age of 8
 pre-operative planning 
 MRI or CT to identify omovertebral bar
 procedures 
 Woodward procedure
 detachment and reattachment of
medial parascapular muscles at
spinous process origin to allow
scapula to move inferiorly and rotate
into more shoulder abduction
  modified Woodward includes
resection of superiormedial border
of scapula in conjunction with
surgical descent
 Schrock, Green procedure
 extraperiosteal detachment of
paraspinal muscles at the scapular
insertion and reinsertion after
inferior movement of scapula with
traction cables
 Clavicle osteotomy
 in conjunction with above
procedures for severe deformity to
avoid brachial plexus injury,
performed before movement of
clavicle.
 Bony resection  
 extraperiosteal resection of proximal
scapular prominence for cosmetic
concerns, may be done with other
procedures or alone
 outcomes 
 Woodward and Green procedures can
improve abduction by 40-50 degrees
o
Congenital o observation 
Pseudoarthrosis of  indications  Operative - very uncommmon
Clavicle  minimal symptoms and cosmetic o ORIF with iliac crest bone grafting at age 3-6 years
deformity  indications
 pain
 functional impairment
 cosmesis
 outcomes
 successful union is usually obtained
 avoid bone graft substitute, higher rates of
 non-union
o
Developmental  o open reduction and spica casting     
Dysplasia of the Hip o abduction splinting/bracing (Pavlik harness)       indications
(DDH)  > 18 months old
 indications
 < 6 months old and reducible hip  failure of closed reduction 
 contraindicated in teratologic o open reduction and femoral osteotomy 
hip dislocations and patients with spina  indications
bifida or spasticity  > 2 years old with residual hip dysplasia 
 requires normal muscle function  anatomic changes on femoral side (e.g.,
for successful outcomes femoral anteversion, coxa valga)
o closed reduction and spica casting   best in younger children (< 4 years old)
 indications  after 4 years old, pelvic osteotomies
 6-18 months old are utilized
 failure of Pavlik treatment o open reduction and pelvic osteotomy 
 indications
 > 2 years old with residual hip dysplasia 
 severe dysplasia accompanied by
significant radiographic changes on the
acetabular side (increased acetabular
index) 
 used more commonly in older children (> 4
yr)
 decreased potential for acetabular
remodeling as child ages
o
Coxa vara o observation alone 
 indications 
 Hilgenreiner-ephyseal angle  Operative 
(normal <25 degrees) 
o corrective valgus derotation osteotomy (VDRO) 
 <45 degrees – unlikely to
 indications 
progress
 Hilgenreiner's physeal angle > 60°
 45-60 – may progress 
 Hilgenreiner's physeal angle between 45-
will require close follow-up if non-symptomatic
 60° if symptomatic (e.g. limp & progression
of varus)
 progressive decrease in neck shaft angle <
110 °
 aftercare 
 hip-spica or abduction pillow x 4-6 weeks
depending on fixation and healing
o
Legg-Calve-Perthes  o femoral and/or pelvic osteotomy 
Disease o observation alone, activity restriction (non-  indications 
weightbearing), and physical therapy (ROM exercises)  children > 8 years of age, especially lateral
 indications  pillar B and B/C
 children < 8 years of age (bone  technique 
age <6 years)   proximal femoral varus osteotomy
 young patients typically do  to provide containment
not benefit from surgery  pelvic osteotomy
 lateral pillar A involvement  Salter or triple innominate
 technique osteotomy
 activity restriction and protected  Shelf arthroplasty may be
weight-bearing during earlier performed to prevent lateral
stages until reossification is subluxation and resultant lateral
complete epiphyseal overgrowth
 main goals of treatment are  outcomes 
to keep the femoral head  children with lateral pillar A and those with
contained and maintain good B under 8 years did well regardless of
motion  treatment
 containment limits  large recent studies show improved
deformity and minimizes outcomes with surgery for lateral pillar B
loss of sphericity   and B/C in children > 8 years (bone age >6
 lessen subsequent
years)   
degenerative
 studies sugggest earlier surgery before
changes
femoral head deformity develops may be
 bracing and casting for
best
containment have not been found
 poor outcome for lateral pillar C regardless
to be beneficial in a large,
 prospective study of treatment
 all patients require periodic clinical o valgus and/or shelf osteotomies
and radiographic followup until  indications 
completion of disease process  hinge abduction 
 outcomes  lateral extrusion of the capital
 good outcomes correlate with femoral epiphysis producing a
a spherical femoral head painful hinge effect on the lateral
 60% do not require acetabulum during abduction
operative intervention  abduction-extension osteotomy 
 good outcomes associated  reposition the hinge segment away from the
with lateral pillar A and acetabular margin
Catterall I groups  correct shortening from fixed adduction
 improve abductor mechanism by improving
abductor muscle contractile length
 Shelf or Chiari osteotomies are also considered
when the femoral head is no longer containable  
o hip arthroscopy
 emerging treatment modality for mechanical
abnormalities in the setting of healed LCPD
 femoroacetabular impingement
o hip arthrodiastasis
 indications 
 controversial indications and outcomes
 technique 
 hip distraction via external fixation
o
SCFE 
o percutaneous in situ fixation   
 indications             
 both stable and unstable slips
 technique 
 one vs. two cannulated screws is controversial
 2 screw constructs have greater biomechanically stable than the single screw constructs 
  benefit of 2 screws needs to be considered in the face of greater screw related complications
including articular surface penetration
 capsulotomy is controversial
 decreases intra-capsular pressure
 primarily indicated in the setting of unstable SCFE: intracapsular pressure in unstable SCFE is double that of
control hips, while pressure in stable SCFE is roughly equal to control hips
 may mitigate intracapsular tamponade, though no clear evidence that this reduces AVN rates 
o contralateral hip prophylactic fixation   
 indications                
 controversial
 current indications are high risk patients for contralateral slip(~ 40-80%) 
 initial slip at young age (< 10 years-old)
 open triradiate cartilage
 obese males
 endocrine disorders (e.g. hypothyroidism)
o open epiphyseal reduction and fixation
 indications 
 controversial
 unstable and severe slips
 technique 
 capital realignment via the modified Dunn procedure
 Operative management of symptoms after initial treatment 
o osteochondroplasty
 indications
 symptomatic femoroacetabular impingement (FAI) of cam lesion from metaphyseal bump
 mild to moderate SCFE deformity (slip angle < 30°)
o
 approach options
 arthroscopic
 limited anterior arthrotomy
 surgical hip dislocation
o proximal femoral osteotomy
 indications 
 painful or function-limiting proximal femoral deformity
  severe SCFE deformity (slip angle >30- 45°)
 absence of severe hip osteoarthritis and osteonecrosis
 technique
 femoral neck cuneiform osteotomy
 can provide greatest correction of deformity
 use is controversial due to high rates of AVN (37%) and osteoarthritis (37%)
 intertrochanteric (Imhauser) osteotomy 
 most commonly used 
 subtrochanteric (Southwick) osteotomy
o
 o surgical soft tissue release
Congenital o reduction with manual manipulation and casting  indications 
Dislocation of the  indications   failure to gain 30° of flexion after 3 months
Knee  Tarek GI, initial treatment for GII of casting
(up to 1 month of age)  Tarek GII (identified after 1 month of age),
 most cases can be treated GIII, and in recurrent cases 
nonoperatively  goal of surgery is to obtain 90° of flexion  
 if both knee and hip dislocated,  percutaneous quadriceps recession (PQR)
then treat knee first   quadriceps tendon lengthening (V-Y
 can't get Pavlik harness on quadricepsplasty or Z lengthening) 
hip if knee dislocated  anterior joint capsule release
 technique   hamstring tendon posterior transposition
 long leg casting on weekly basis  collateral ligaments mobilization
  postoperative 
 cast in 45 to 60° flexion for 3 to 4 weeks
o
 o proximal tibia/fibula valgus osteotomy  
 36 o brace treatment with KAFO   overcome the varus/flexion/internal rotation
0%  indications  deformity
Infantile Blount's  Stage I and II in children < 3 years  indications 
Disease (tibia vara)
 Stage I and II in children > 3 years 
 technique   Stage III, IV, V, VI 
 bracing must continue for  age ≥ 4y (all stages) 
approximately 2 years for
 resolution of bony changes failure of brace treatment 

 outcomes   progressive deformity
 improved outcomes if unilateral  metaphyseal-diaphyseal angles > 20
 poor results associated degrees
with obesity and bilaterality  technique
 if successful, improvement should  perform osteotomy below tibial tubercle
occur within 1 year  staged procedures may be required for
Stage IV, V, VI
 epiphysiolysis required in stage V and VI
 outcomes
 risk of recurrence is significantly lessened if
performed before 4 years of age
o growth modulation
 technique
 tension band plate and screws 
o physeal bar resection
 indication
 at least 4y of growth remaining
 technique 
 perform together with osteotomy
 interpositional material is usually fat or
PMMA
o hemiplateau elevation 
 technique 
 may be performed together with osteotomy
o
o observation or bracing is unlikely to be successful o lateral tibia and fibular epiphysiodesis 
Adolescent Blount's - treatment is always surgical  indications 
Disease   indications   mild to moderate deformity with growth
 mild cases only remaining
 outcomes   outcomes 
 poor outcomes - will progresse and  up to 25% may require formal osteotomy
cause medial joint pain and altered due to residual deformity
kinematics
  early onset arthritis is common in o proximal tibia/fibula osteotomy 
untreated cases  indications 
 more severe cases in the skeletally mature
 can be achieve with a valgus
producing tibial osteotomy and
plating   
 can be achieved with gradual
correction with external fixation
 outcomes 
 multiplanar external fixation following
osteotomy allows gradual angle and length
correction and decreases risk on
neurovascular structures
o distal femoral osteotomy or epiphysiodesis
 indications 
  for distal femoral varus deformity of 8
degrees or greater
o
Genu Valgum o hemiepiphysiodesis or physeal tethering (staples, screws, or
(knocked knees)  o observation plate/screws) of medial side   
 indications  indications
 first line of treatment  > 15-20° of valgus in a patient <10 years of
 genu valgum <15 degrees in a age
child <6 years of age  if line drawn from center of femoral head to
o bracing  center of ankle falls in lateral quadrant of
 indications 
tibial plateau in patient > 10 yrs of age   
 rarely used 
 technique
 ineffective in pathologic
 to avoid physeal injury place them
genu valgum and
extraperiosteally
unnecessary in physiologic
 to avoid overcorrection follow patients often
genu valgum
 growth begins within 24 months after
removal of the tether
o distal femoral varus osteotomy   
  indications 
 insufficient remaining growth for
hemiepiphysiodesis 
 complications
 peroneal nerve injury 
 perform a peroneal nerve release
prior to surgery
 gradually correct the deformity
 utilize a closing wedge technique
o
Scoliosis (Neurofibrom o decompression, anterior spinal fusion (ASF) & posterior (PSF)
atosis) o observation vs. bracing with instrumentation
 bracing is not effective for dystrophic form  indications 
 nondystrophic scoliosis in NF is treated  dystrophic scoliosis 
like adolescent idiopathic scoliosis  perform early in young children (< 7
yrs) with dystrophic curves
 complications 
 high rate of pseudoarthrosis with PSF alone
(40%) 
 pseudoarthrosis rate still high with
ASF&PSF (10%)
 some recommend augmenting the
PSF with repeat iliac crest bone
grafting 6 months after the primary
surgery
o
Anterolateral Tibial  o bone grafting with surgical fixation     
Bowing (Neurofibromat o bracing in total contact orthosis      indications 
osis)  in bowing with pseudoarthrosis or fracture
 indications 
 bowing without pseudoarthrosis or o amputation with prosthesis fitting
fracture (goal is to prevent further  indications 
bowing and fractures)  three failed surgical attempts
 spontaneous remodeling is not  Syme's often superior to BKA due to
expected atrophic and scarred calf muscle in these
  osteotomy for bowing alone is patients
contraindicated o

Fibular Deficiency 
(anteromedial o observation
bowing)  shoe lift
 bracing
 Operative 
o contralateral epiphysiodesis alone
 indications
 mild projected LLD (<5cm or <10%)
 stable, plantigrade foot
o limb lengthening procedure alone
 indications 
 plantigrade, functional foot with a stable ankle
 LLD < 10%
 technique
 involves resection of fibular anlage to avoid future foot problems
o contralateral epiphysiodesis + limb lengthening procedure
 indications
 moderate LLD (10-30%)
o Syme amputation (preferred to Boyd amputation)
 Boyd is more bulbous and only about 1cm longer
 indications 
 nonfunctional, deformed, unstable foot
 LLD > 30%
 unable to cope psychologically with multiple limb lengthening procedures
 cosmesis
 technique 
 amputation usually done at ~1 year of age to allow early prosthesis fitting, better psychosocial acceptance
 results 
 88% satisfaction with amputation vs 55% satisfaction with limb lengthening
o
Anterolateral Bowing  o surgical fixation
& Congenital o bracing in clamshell orthosis or patellar tendon bearing  indications
Pseudoarthrosis of (PTB) orthosis  bowing with pseudarthrosis or fracture 
Tibia  indications o amputation 
 Children of ambulatory age (weight  indications 
bearing)  typically indicated after multiple failed
 bowing without pseudarthrosis or surgical attempts at union
fracture  severe limb length discrepancy
 spontaneous remodeling is  dysfunctional angular deformity
not expected  Method- Syme or Boyd amputation
 goal is to prevent further bowing and o
fractures
 osteotomy for bowing alone is
contraindicated
 technique 
 maintained until skeletal maturity

Tibial Deficiency  knee disarticulation followed by prosthestic fitting

o indications 
 complete  absence of the tibia
 no active knee extension present (most cases)
 tibiofibular synostosis with modified Syme amputation
o indications 
 proximal tibia present with intact extensor mechanism and minimal flexion contracture 
 Syme/Boyd amputation
o indications 
 ankle diastasis
 Brown Procedure (centralization of fibula under femur) 
o no longer recommended due to high failure rate
o
Leg Length  o shortening of long side via epiphysiodesis of femur, tibia, or both
Discrepancy (LLD) o shoe lift or observation only     indications 
 indications   2-5 cm projected LLD 
 < 2 cm projected LLD at maturity o limb lengthening of short side   
 outcomes   indications
  not associated with scoliosis or  > 5 cm projected LLD
back pain  lengthening often combined with a
shortening procedure (epiphysiodesis,
ostectomy) on long side
o physeal bar excision
 indications 
 bony bridge involves <50% of physis
 at least 2 years left of growth
o amputation and prosthetic fitting
 indications
 non-reconstructable limb
 > 20 cm projected LLD
o
  o ambulation without prosthesis
 18 o observation  limb lengthening with or without contralateral
0%  indications  epiphysiodesis
Proximal Femoral  often in children with bilateral  indications 
Focal Deficiency deficiency  predicated limb length discrepancy
o extension prosthesis of <20 cm  at maturity
 indications   stable hip and functional foot
 less attractive option due to large  femoral length >50% of opposite
proximal segment of prosthesis side
 assists patient when attempting to  femoral head present (Aitken
pull self up to stand classifications A & B)
 contraindications 
 unaddressed coxa vara, proximal
femoral neck pseudoarthrosis, or
acetabular dysplasia
o ambulation with a prosthesis
 knee arthrodesis with foot ablation
 indications: 
 ipsilateral foot is proximal to the
level of contralateral knee 
 prosthetic knee will not be below the
level of the contralateral knee at
 maturity
 need for improved prosthetic fit,
function, and appearance
 femoral-pelvic fusion (Brown's procedure)
 indications 
 femoral head absent (Aiken
classifications C & D)
 Van Ness rotationplasty 
 indications 
 ipsilateral foot at level of
contralateral knee
 ankle with >60% of motion
 absent femoral head (Aiken
classifications C & D)
 surgical technique 
 180 degree rotational turn through
the femur
 ankle dorsiflexion becomes knee
flexion
 allows the use of a below-knee
prosthesis to improve gait and
efficiency
 amputation
 indications 
 femoral length <50% of opposite
side
 surgical technique
 preserve as much length as possible
 amputate through the joint, if possible, in
order to avoid overgrowth which can lead to
difficult prosthesis fittingfit for prosthesis for
lower extremity after 1 year
o
 o derotational femoral osteotomy
Femoral Anteversion o observation and parental reassurance  indications 
  indications   < 10° of external rotation on exam in
 most cases usually an older child (>8-10 yrs)
resolve spontaneously by age 10  rarely needed
 technique   technique 
 bracing, inserts, PT, sitting  typically performed at the intertrochanteric
restrictions do not change natural level
history  amount correction needed can be
 calculated by (IR-ER)/2
o
 o derotational supramalleolar tibial osteotomy vs. proximal
Internal Tibial Torsion o observation and parental education osteotomy
 indications  indications
 most cases   rarely required
 outcomes   child > 6-8 years of age with functional
 usually resolves spontaneously by problems and thigh-foot angle >15 degrees
age 4  technique
 bracing/orthotics do not change  associated with lower complications than
natural history of condition proximal osteotomy
 fixaton with plate or smooth K wires
 intramedullary nail fixation if skeletally
mature
o
External Tibial  o supramalleolar derotational osteotomy or proximal tibial
Torsion o rest, rehab, and activity modifications derotational osteotomy 
 indications  indications 
 first line of treatment  surgery is reserved for children older than 8
 years of age with external tibial torsion
greater than three standard deviations
above the mean ( >40 degrees external).
 more likely to require surgery than internal
tibial torsion
o
 metatarsus  a benign condition that resolves spontaneously in 90% of  metatarsus adductus 
adductus  cases by age 4    o tarsometatarsal capsulotomies
 another 5% resolve in the early walking years (age 1-4  indications
years)  aged 2-4yr with failed nonop management
 passively correctable : stretching at home o lateral column shortening and medial column opening
 rigid : serial casting osteotomies, multiple metatarsal osteotomies
 indications
 age > 5yrs (as the deformity may correct
with growth until this age)
 resistant cases that fail nonoperative
treatment (usually with medial skin crease)
 severe deformity produces difficulty with
shoeware and pain
 technique 
 lateral column shortening done
with cuboid closing wedge osteotomy
 medial column lengthening includes a
cuneiform opening wedge osteotomy with
medial capsular release and abductor
hallucis longus recession (for atavistic first
toe)
 serpentine foot 
o opening wedge and closing wedge osteotomies
 indications 
 indicated if serpentine deformity is
symptomatic and significantly limits function
 operative treatment is difficult and often
times deformity is accepted and observed
 technique 
 calcaneal osteotomy for hindfoot valgus
 possible midfoot osteotomies to correct
midfoot and forefoot deformities
 multiple metatarsal osteotomies with
forefoot pinning and tarsometatarsal
capsular release (Hamen procedure) 
o
Clubfoot (congenital  o posteromedial soft tissue release and tendon lengthening
talipes equinovarus) o Ponseti method of serial manipulation and casting     indications 
 resistant and/or recurrent feet in young
   children which have failed Ponseti casting
 Ponseti method is the gold standard in and bracing
most of the world  "rocker bottom" feet that develop following
 indications  serial casting which failed non-surgical
 this is the standard of care for
untreated clubfeet   intervention 
 outcomes  syndrome-associated clubfoot if casting
 Ponseti method has a > 90% fails
success rate in avoding  when performed, it is often done at 9-10
comprehensive surgical release months of age in non-syndromic feet so
 children can be expected to walk, walking is not delayed 
run and be fully active in the  outcomes 
 requires postoperative casting for optimal
absence of other comorbidities  results
o French method of daily physical therapy, manipulation  long-term stiffness and pain are relatively
and splinting common
 indications   extent of soft-tissue release correlates
 rarely used in the United States inversely with long-term function of the foot
 outcomes  
and patient 
 good outcomes in skilled hands
o medial column lenthening or lateral column-shortening
osteotomy, or cuboid decancellation
 indications 
 often combined with initial surgical clubfoot
release in children more than 2-3 years old 
 may be performed in 3-10 years old
children with recurrent deformity and "bean-
shaped" foot
o talectomy
 indications 
 in severe, rigid recurrent clubfoot in children
with arthrogryposis
 age typically 6-10 years
 o multiplanar supramalleolar osteotomy  
 indications 
 rarely necessary
 salvage procedure in older children with
complex, rigid, multiplanar clubfoot
deformities that have failed conventional
operative management
 salvage procedure in older children (8-10
yrs) with an insensate foot
o ring fixator (Taylor Spatial Frame) application and gradual
correction
 indications 
 complex deformity resistant to standard
methods of treatment
 recurrence of deformity is very high after
frame removal
o triple arthrodesis
 indications 
 almost never indicated
 contraindicated in insensate feet due to
rigidity and resultant ulceration
o
Cavovarus Foot in  o soft tissue reconstruction
Pediatrics & Adults o accomodative shoe wear  indications
 indications  failure of nonoperative treatment
 rarely sufficient except in mild  performed with a combination of the following
deformity procedures
o full-length semi-rigid insole orthotic with a depression  plantar release
 indications  
for the first ray and a lateral wedge   
 indications  cavus deformity
 mild cavus foot deformity in adult  technique  
(not indicated in children)  plantar fascia release
o supramalleolar orthosis (SMO)   Steindler stripping (release
 indications short flexors off the
  more severe cavovarus deformity calcaneus)
recalcitrant to shoewear  peroneus longus to brevis transfer 
accomodations  indications  
o ankle foot orthosis (AFO)  plantar flexed first ray
 indications  technique  
 may be needed if equinus also  decreases plantarflexion
present, resulting in force on first ray without
equinocavovarus foot deformity weakening eversion
 works best if equinus is a dynamic  posterior tibial tendon transfer
defomrity (not rigid)  indications  
o lace-up ankle brace and/or high-top shoe or boots  muscle imbalance  
 indications  posterior tibialis
 may consider in moderate typically is markedly
deformities when patient does not stronger than
tolerate the more rigid bracing with evertors and
an SMO or AFO maintains strength for
a long time in most
cavovarus feet
 may consider transfer of
posterior tibialis to dorsum of
foot if severe dorsiflexion
weakness of anterior tibialis
 lengthening of gastrocnemius or
tendoachilles (TAL) 
 indication  
 true ankle equinus
 gastrocnemius recession
produces less calf weakness
and can be combined with
plantar release
simultaneously
 TAL should be staged
several weeks after plantar
release
  1st metatarsal dorsiflexion osteotomy 
 indications  
 flexible hindfoot
varus deformities (normal
Coleman block test)   
 corrects the forefoot
pronation driving the
hindfoot deformity
 lateral ankle ligament
reconstruction (e.g. Broström ligament
reconstruction) 
 indications  
 chronic ankle instability due
to lignamentous
incompetence following long-
standing cavovarus
 Jones transfer(s) of EHL to neck of 1st MT
and lesser toe extensors to 2nd-5th MT
necks 
 indication  
 toe clawing combined with
cavus foot   
 performed if the indication is
met and time permits
 the modified Jones transfer
for the hallux includes an IP
joint fusion 
o lateralizing calcaneal valgus-producing osteotomy
 indications  
 rigid hindfoot varus deformity (abnormal
Coleman block test) 
o triple arthrodesis
 indication  
  almost never indicated due to very poor
long-term results
o
Tarsal Coalition  o coalition resection with interposition graft, +/- correction of
o observation, shoe inserts associated foot deformity   
 indications   indications 
  unclear.   persistent symptoms despite nonoperative
 techniques
management   
 medial arch support and preserved
 coalition involves <50% of joint surface
hindfoot alignment
area
 outcomes
 techniques
 In rigid flat feet shoe inserts may
 open vs arthroscopic coalition resection
be the cause of discomfort.
 interposition material 
o immobilization with casting, analgesics
 extensor digitorum brevis
 indications 
(calcaneonavicular coalition)
 initial treatment for symptomatic
 split flexor hallucis longus
cases      tendon (talocalcaneal coalition)
 techniques  interposed fat graft
 below-knee walking cast for six-  bone wax
weeks  correction of associated hindfoot, midfoot or
 outcomes  forefoot deformities
 up to 30% of symptomatic patients  calcaneal osteotomy for hindfoot
will become pain-free with a short valgus
period of immobilization  calcaneal lengthening to create arch
after resection
 heel cord lengthening if
intraoperative ankle dorsiflexion is
not past neutral
 outcomes 
 80-85% will experience pain relief
 poor outcomes
 coalition resection >50% size of joint
surface area
 uncorrected hindfoot valgus 
  associated degenerative changes 
o subtalar arthrodesis
 indications 
 role has not been well established
 consider if coalition involves >50 % of the
joint surface of a talocalcaneal coalition
 technique
 open vs. arthroscopic 
 consider an associated calcaneal
osteotomy with severe hindfoot
malalignment
o triple arthrodesis (subtalar, calcaneocuboid, and talonavicular) 
 indications 
 advanced coalitions that fail resection
 diffuse associated degenerative changes
affecting calcaneocuboid and talonavicular
joints
 technique
 open vs. arthroscopic
o
Congenital Vertical  o surgical release and talonavicular reduction and pinning   
Talus o serial manipulation and casting  indications 
 indications   indicated in most cases
 indicated preoperatively to stretch  performed at 6-12 months of age
the dorsolateral soft-  technique 
tissue structures   involves pantalar release with concomitant
 foot is manipulated into inversion lengthening of peroneals, Achilles, and toe
and plantarflexion extensors 
 typically still requires closed vs open  talonavicular joint is reduced and pinned
pinning of the talonavicular joint with while reconstruction of the plantar
percutaneous achilles tenotomy  calcaneonavicular (spring) ligament is
performed 
 concomitant tibialis anterior transfer to talar
neck
 o minimally invasive correction
 indications 
 new technique performed in some centers
to avoid complications associated with
extensive surgical releases
 technique
 principles for casting are similar to the
Ponseti technique used clubfoot
 serial casting utilized to stretch contracted
dorsal and lateral soft tissue structures and
gradually reduced talonavicular joint
 once reduction is achieved with cast,
closed or open reduction is performed and
secured with pin fixation 
 percutaneous achilles tenotomy is required
to correct the equinus deformity
o talectomy
 indicated in resistant case
o triple arthrodesis
 as salvage procedure
o
Flexible Pes  o Achilles tendon or gastrocnemius fascia lengthening
Planovalgus (Flexible o observation, stretching, shoewear modification,  indications
Flatfoot) orthotics  flexible flatfoot with a tight heelcord with
 indications painful symptoms refractory to stretching
 asymptomatic patients, as it almost o calcaneal lengthening osteotomy (with or without cuneiform
always resolves spontaneously osteotomy)
 counsel parents that arch  indications 
will redevelop with age  continued refractory pain despite use of
 techniques extensive conservative management
 athletic heels with soft arch  rarely indicated
support or stiff soles may be  technique 
helpful for symptoms   calcaneal lengthening osteotomy
 orthotics do not change natural (Evans) 
 history of disease     with or without a cuneiform
 UCBL heel cups may be indicated osteotomy and peroneal tendon
for symptomatic relief of advanced lengthening
 sliding calcaneal osteotomy
cases   corrects the hindfoot valgus
 rigid material can lead to  plantar base closing wedge osteotomy of
poor tolerance the first cuneiform
 stretching for symptomatic patients  corrects the supination deformity
with a tight heel cord o
 

Congenital Hallux o abductor hallucis muscle release
Varus (Atavistic Great o observation alone  indication
Toe)  indication  mild and resistant deformities
 rare as deformity is thought to o excision of central portion of epiphyseal bracket 
worsen with age  indication
 surgical correction often proposed  if epiphyseal bracket found to be the cause
in infancy of Hallux Varus
  resumption of longitudinal growth common if
performed at a young age
 secondary corrective realignment or lengthening is
sometimes needed
o Farmer technique 
 indication 
 moderate to severe deformities
 technique creates syndactyly between the 2nd toe
and hallux
 maintains deformity correction
o
Cerebral Palsy - Hip  Nonoperative
Conditions o observation
 mild cases
o Physical therapy never shown to prevent hip subluxation
o Abduction bracing alone does not reduce dislocations and may cause windswept deformity
  Operative - soft tissue procedures
o Hip adductor and psoas release with abduction bracing
 indications  
 children < 4 years and Reimers index > 40% 
 Consider for "at risk" hips (see chart above)
 any evidence of progressive subluxation if less than 8-year-old
 May also be used as a supplement to bone procedures
 Operative - reconstuctive procedures
o proximal femoral osteotomy with shelf-producing (Dega) osteotomy and soft-tissue release
 indications 
 children > 4 years old or Reimers index > 60% 
 best to treat all pathology at single stage if the patient has a severely dysplastic CP hip 
 Operative - salvage procedures
o valgus support osteotomy (femoral head resection + valgus subtrochanteric femoral osteotomy (e.g McHale Technique)   
 indication 
 salvage technique for symptomatic and chronically dislocated hips in cerebral palsy
o Castle resection-interposition arthroplasty
 indications 
 chronically dislocated hips, especially in the adult CP population
 unable to walk, stand to transfer (GMFCS 5)
o total hip arthroplasty
 indications 
 ambulatory patients and wheelchair bound who can stand to transfer
 results 
 85% 10 year survival in CP patients
o hip arthrodesis
 indications 
 young patients
 ambulatory patients and wheelchair bound who can stand to transfer
o Girdlestone procedure
 indications 
 no longer performed because uniformly causes pain 
 caused by lack of interposition of soft tissue between cut femur and acetabulum leads to proximal
femoral migration
 o
Duchenne Muscular  nonoperative 
Dystrophy  o bracing is contraindicated 
 may interfere with respiration
scoliosis
 operative    
o early PSF with instrumentation 
 indications 
 curve 20-30° in nonambulatory patient 
 treat early before pulmonary function declines
 can wait longer ~ 40° if responding well to corticosteroids
 FVC drops ≤ 35% 
 rapidly progressive curve 
o PSF with instrumentation to pelvis
 indications 
 curves ≥ 40°
 pelvic obliquity ≥ 10°
 lumbar curve where apex is lower than L1
 complications 
 malignant hyperthermia is common intraoperatively
 pretreat with dantrolene
 intraoperative cardiac events
o anterior and posterior spinal fusion
 indications 
 rarely for stiff curves
o
o soft tissue reconstruction
o accomodative shoe wear  indications
Charcot-Marie-Tooth  indications   flexible deformity in adolescents with closed
Disease  rarely sufficient except in mild physes 
deformity  failed conservative management of fixed
o full-length semi-rigid insole orthotic with a depression deformities
for the first ray and a lateral wedge   performed with a combination of the following
 indications  procedures
  mild cavus foot deformity in adult  plantar release (plantar fascia +/- Steindler
(not indicated in children) stripping, i.e. release of short flexors off the
o supramalleolar orthosis (SMO)  calcaneus) 
 indications   indications 
 more severe cavovarus deformity  cavus
recalcitrant to shoewear  peroneus longus to brevis transfer
accomodations  indications 
o ankle foot orthosis (AFO)  plantar flexed first ray
 indications  rationale 
 may be needed if equinus also  decreases plantarflexion
present, resulting in force on first ray without
equinocavovarus foot deformity weakening eversion
 works best if equinus is a dynamic  posterior tibial tendon transfer
defomrity (not rigid)  indications 
o lace-up ankle brace and/or high-top shoe or boots  muscle imbalance: posterior
 indications  tibialis typically is markedly
 may consider in moderate stronger than evertors and
deformities when patient does not maintains strength for a long
tolerate the more rigid bracing with time in most cavovarus feet
an SMO or AFO  may consider transfer of
posterior tibialis to dorsum of
foot if severe dorsiflexion
weakness of anterior
tibialis 
 lengthening of gastrocnemius or
tendoachilles (TAL)
 indications 
 true ankle equinus
 outcomes 
 gastrocnemius recession
produces less calf weakness
and can be combined with
plantar release
simultaneously (TAL should
 be staged several weeks
after plantar release)
 Jones transfer(s) of EHL to neck of 1st MT
and lesser toe extensors to 2nd-5th MT
necks 
 indications 
 toe clawing combined with
cavus foot   
 performed if the indication is
met and time permits
o 1st metatarsal dorsiflexion osteotomy 
 indications 
 flexible hindfoot cavus deformities (normal
Coleman block test and/or passive hindfoot
eversion past neutral)   
o triple arthrodesis, lateral calcaneal slide or closed-wedge
osteotomy
 indications 
 performed if deformity does not correct with
Coleman block test.
o
Arthrogryposis  o closed reduction
Teratologic Hip o observation alone   indications
Subluxation &  rarely successful
 observe alone while addressing other
Dislocation o medial open reduction with possible femoral shortening 
hand/foot deformities
 indications   done at ≥ 6 months of age
 bilateral dislocations  indications 
(controversial)  unilateral teratologic dislocation   
 unilateral dislocation in older child  may lead to worse function if it leads to a hip
(controversial) flexion contracture because flexion deformities
o Pavlik harness and rigid abduction brace are unlikely to worsen the patient's gait
succeed o
 
 
Arthrogryposis  soft tissue releases (especially hamstrings)
Knee Contractures o indications
 flexion contracture >30 degrees
 best performed early (6-9 months of age) 
 perform before hip reduction to assist in maintenance of reduction
 femoral angulation through guided growth (epiphysiodesis)
o indications
 useful in conjunction with osteotomies
o outcomes
 may not effectively correct chronic poor quadriceps function
 supracondylar femoral osteotomy
o indications
 may be needed to correct residual deformity at skeletal maturity
o
Arthrogryposis  Clubfoot 
Foot Conditions o treatment 
 nonoperative
 Ponseti casting  
 indications 
 useful in many patients
 operative
 soft tissue release
 indications 
 first line of treatment in rigid clubfoot
 failed Ponseti casting in more flexible types
 talectomy vs. triple arthorodesis
 indications 
 failed soft tissue releases
 triple arthrodesis in adolescence
 Vertical Talus 
o treatment 
 operative 
  soft tissue releases
 indications 
 first line of treatment
 talectomy
 indications 
 if deformities recur despite soft tissue releases
o
Equinovarus foot  AFO fitting  split anterior tibial tendon transfer (SPLATT)
 physical therapy  flexor hallucis longus tendon transfer to the dorsum of the foot
 Phenol or botox injections and release of the flexor digitorumlongus and brevis tendons at
 the base of each toe
 gastrocnemius or achilles lengthening 
o
Foot drop  Observation  Posterior tibial tendon transfer to lateral cuneiform +/- gastroc or
 AFO bracing
 Therapy - stretching and supple joints Achilles tendon lengthening   
 o
High Ankle Sprain &  o syndesmosis screw fixation
Syndesmosis Injury o non-weight-bearing CAM boot or cast for 2 to 3 weeks  indications 
 indications   syndesmotic sprain (without fracture) with
 syndesmotic sprain without instability on stress radiographs
diastasis or ankle instability  syndesmotic sprain refractory to
 technique  conservative treatment
 delayed weight-bearing until pain  syndesmotic injury with associated fracture
free that remains unstable after fixation of
 physical therapy program using a fracture
brace that limits external rotation  outcomes 
 outcomes   excellent functional outcomes if
 typically display a notoriously syndesmosis is accurately reduced 
prolonged and highly  often requires removal
variable recovery period 
o syndesmosis fixation with suture button 
 recovery may extend to twice that
of standard ankle sprain  indications
  same as for screw fixation
  technique
 fiberwire suture with two buttons tensioned
around the syndesmosis
 may be performed in addition to a screw
 outcomes
 early results promising with some showing
earlier return to activity when compared to
screw fixation
 does not require removal
o
Ankle Sprain  o anatomic reconstruction vs. tendon transfer with tenodesis
o RICE, elastic wrap to minimize swelling, followed by  indications 
therapy       Grade I-III that continue to have pain and
 indications instability despite extensive nonoperative
 Grade I, II, and III injuries management
 technique  Grade I-III with a bony avulsion
 initial immobilization   technique (see below)
 may require short period o arthroscopy
(approx. 1 week) of weight-  indications 
bearing immobilization in a  recurrent ankle sprains and chronic pain
walking boot, aircast or caused by impingement lesions 
walking cast, but early  anteriorinferior tibiofibular
mobilization facilitates a ligament impingement   
better recovery  posteromedial impingement lesion
 grade III sprains may of ankle
benefit from 10 days of  often used prior to reconstruction to
casting and evaluate for intra-articular
nonweightbearing  pathology 
 therapy  procedure 
 early phase   debride impinging tissue
 early functional o
rehabilitation begins
with motion
exercises and
 progresses to
strengthening,
proprioception, and
activity-specific
exercises 
 strengthening phase 
 once swelling and
pain have subsided
and patient has full
range of motion
begin
neuromuscular
training with a focus
on peroneal
muscles strength
and proprioception
training       
 
 a functional
brace that controls
inversion and
eversion is typically
used during the
strengthening
period and used as
prophylactic
treatment during
high-risk activities
thereafter
 outcomes 
 early functional rehabilitation
allows for the quickest return to
physical activity       
 supervised physical therapy has
 shown a benefit in early follow-up
but no difference in the long term

  o open reduction and rigid internal fixation 
 30 o cast immobilization for 8 weeks    indications 
0%  indications   any evidence of instability (> 2mm shift)   
Lisfranc Injury  no displacement on weight-bearing
     
and stress radiographs and no
 favored in bony fracture dislocations as
evidence of bony injury on CT
opposed to purely ligamentous injuries
(usually dorsal sprains)
 outcomes 
 certain nonoperative candidates 
 anatomic reduction required for a good
 nonambulatory patients
result
 presence of serious
o primary arthrodesis of the first, second and third tarsometatarsal
vascular disease
 severe peripheral joints
neuropathy  indications 
 instability in only the  purely ligamentous arch injuries     
transverse plane  delayed treatment 
 chronic deformity
 outcomes 
 level 1 evidence demonstrates equivalent
functional outcomes and decreased rate of
hardware removal or revision surgery
compared to primary ORIF       
 primary arthodesis is an alternative to ORIF
in patients with any evidence of instability
with possible benefits 
 medial column tarsometatarsal fusion
shown to be superior to combined medial
and lateral column tarsometatarsal
arthrodesis   
o midfoot arthrodesis
 indications 
 destabilization of the midfoot's architecture
 with progressive arch collapse and forefoot
abduction
 chronic Lisfranc injuries that have led
to advanced midfoot arthrosis and have
failed conservative therapy
o
  
 15 o protected weight bearing in stiff soled shoe, boot or o intramedullary screw fixation                      
0% cast     
5th Metatarsal Base  
 indications   indications  
Fracture  zone 1 fracture without rotational  zone 1 fractures with rotational
displacement displacement or skin tenting
 outcomes  zone 2 (Jones fracture) in elite or
 union achieved by 8 weeks,
fibrous unions are infrequently competitive athletes     
symptomatic  minimizes possibility of nonunion or
 early return to work but symptoms prolonged restriction from activity
may persist for up to 6 months  zone 3 fractures in athletic individuals,
cavovarus alignment, or with
o non-weight bearing short leg cast for 6-8 weeks  sclerosis/nonunion
 indications  outcomes 
 zone 2 fracture in recreational  bony union rates approaching 100% in
athlete  most series
 zone 3 fracture o open reduction internal fixation with plate and screws
 outcomes   indications
 high non-union rate and risk of re-  same as intramedullary screw fixation
fracture approaching 33% in zone  salvage for nonunion following
2 fractures intramedullary screw fixation
 outcomes
 early data show plate and screw construct
has equivalent strength to intramedullary
fixation
o
Metatarsal fractures  Nonoperative  o percutaneous vs open reduction and fixation
o stiff soled shoe or walking boot with weight bearing as  indications
 tolerated  open fractures
 indications  first metatarsal 
 first metatarsal   any displacement  
 non-displaced fractures  no intermetatarsal ligament
 second through fourth (central) support
metatarsals  30-50% of weight bearing
 isolated fractures
with gait
 non-displaced or minimally
 central metatarsals 
displaced fractures
  sagittal plane deformity more than
 stress fractures 
10 degrees
 second metatarsal most
 >4mm translation
common
 multiple fractures
 look for metabolic bone
 techniques
disease
 antegrade or retrograde pinning
 evaluate for cavovarus foot
 lag screws or mini fragment plates in length
with recurrent stress
unstable fracture patterns
fractures
 maintain proper length to minimize risk of
transfer metatarsalgia
 outcomes
 limited information available in literature
o
Navicular stress  o open reduction and internal fixation
fracture o cast immobilization with no weight bearing     indications
 indications   high level athletes
 any navicular stress fracture,  nonunion of navicular stress fracture
regardless of type, can be initially  failure of cast immobilization and non
treated with cast immobilization weight bearing
and nonweight bearing for 6-8 o
weeks with high rates of
success 

Navicular traumatic  o fragment excision
fracture o cast immobilization with no weight bearing  indications 
 indications   avulsion fractures that failed to improve
  acute avulsion fractures  with nonoperative modalities
 most tuberosity fractures  tuberosity fractures that went on to
 minimally displaced Type I and II symptomatic nonunion
navicular body fractures o open reduction and internal fixation
 indications 
 avulsion fractures involving > 25% of
articular surface
 tuberosity fractures with > 5mm diastasis or
large intra-articular fragment
 displaced or intra-articular Type I and II
navicular body fractures 
 technique 
 medial approach 
 used for Type I and II navicular
body fractures
o ORIF followed by external fixation vs. primary fusion
 indications
 Type III navicular body fractures 
 navicular avascular necrosis
 technique 
 must maintain lateral column length
 fusion of talonavicular and
naviculocuneiform joints in navicular
avascular necrosis
o
Achilles Tendon o functional bracing/casting in resting equinus o open end-to-end achilles tendon repair 
Rupture  indications   indications
 acute injuries with surgeon or  acute ruptures (approximately <6 weeks)
patient preference for non-  outcomes
operative management  decreased rate of re-rupture compared to
 sedentary patient non-operative management
 medically frail patients  new Level 1 evidence has
 outcomes  suggested no difference in re-
 equivalent plantar flexion rupture rates with functional rehab
 strength compared to operative protocol
management no significant difference in plantar flexion
 increased risk of re- strength with functional rehab protocol
rupture compared to operative o percutaneous Achilles tendon repair
management   indications
 new studies show that this  concerns over cosmesis of traditional scar
may not be significant if  outcomes
functional rehabilitation  higher risk of sural nerve damage 
 lesser risk of wound complications/infection
used 
compared with open repair
 fewer complications compared to
o reconstruction with VY advancement     
operative treatment 
 indications

 chronic ruptures with defect < 3cm
o flexor hallucis longus transfer +/- VY advancement of
gastrocnemius          
 indications
 chronic ruptures with defect > 3cm
 requires a functioning tibial nerve
o
Peroneal tendon  o acute repair of superior peroneal retinaculum and deepening of
dislocation o short leg cast immobilization and protected weight the fibular groove
bearing for 6 weeks  indications 
 indications  acute tendon dislocations in serious
 all acute injuries in nonprofessional athletes who desire a quick return to a sport
athletes or active lifestyle 
 technique  presence of a longitudinal tear   
 tendons must be reduced at the
o groove-deepening with soft tissue transfer and/or osteotomy   
time of casting
 outcomes  
 success rates for nonsurgical  indications
management are only marginally  chronic/recurrent dislocation 
better than 50%.  technique
  less able to reconstruct SPR so treatment
focuses on other aspects of peroneal
 stability
 typically involves groove-deepening in
addition to soft tissue transfers or bone
block techniques (osteotomies to further
contain the tendons within the sulcus)
 plantaris grafts can act to reinforce the SPR
 hindfoot varus must be corrected prior to
any SPR reconstructive procedure
o
Peroneal Brevis Tears  nonoperative  o core repair and tubularization of the tendon   
o NSAIDs, activity restriction and a walking boot are often the  indications 
first line of treatment  simple tears
o failure rate may be as high as 83% o debridement of the tendon with tenodesis of distal and proximal
 ends of the brevis tendon to the peroneus longus or
reconstruction with allograft 
 indications 
 complex tears with multiple longitudinal
tears and significant tendinosis (> 50% of
the tendon involved) 
o debridement of both tendons with interposition allograft
 indications 
 complex tears of both tendons with
(involving over 50% of tendon substance)
with preserved muscle excursion
o debridement of both tendons with FHL transfer
 indications 
 complex tears of both tendons with
(involving over 50% of tendon substance)
with no muscle excursion
o hindoot osteotomy with peroneal tendon pathology 
 varus hindfoot alignment contributes to peroneal
pathology
 consider calcaneal osteotomy or subtalar
arthrodesis in patient with hindfoot varus and
 peroneal pathology
o
Anterior Tibialis o direct repair
Tendon Rupture o ankle-foot orthosis  indications
 indications  acute injury (<6 week) injuries in an active,
 low demand patient high demand patient   
o casting  should be attempted up to 3 months out
 indications 
 outcomes 
 partial ruptures
 surgical repair leads to improved AOFAS
scores and improved levels of activity
 some residual weakness of dorsiflexion is
expected
o reconstruction 
 indications 
 most often required in chronic (>6 week)
old injuries
o
Insertional Achilles  o retrocalcaneal bursa excision, debridement of diseased tendon,
tendonitis o activity modification, shoe wear modification, therapy calcaneal bony prominence resection 
 indications   indications 
 first line of treatment  failure of nonoperative management and
 techniques  < 50% of Achilles needs to be removed
 therapy   technique 
 physical therapy with  midline, lateral, or medial J-shaped
eccentric training  incisions
 gastrocnemius-soleus o tendon augmentation or transfer (FDL, FHL, or PB) vs. suture
stretching anchor repair 
 shoe wear   indications
 heel sleeves and  when > 50% of Achilles tendon insertion
pads (mainstay of must be removed during thorough
nonoperative treatment) debridement
 small heel lift  heavier patients with more severe disease
 locked ankle AFO for 6-9  FHL transfer has been associated with increased
months (if other
 nonoperative modalities ankle plantar flexion
fail) o
 injections 
 avoid steroid injections due
to risk of Achilles tendon
rupture

Achilles  o percutaneous tenotomies
Tendonopathy o activity modification, shoe wear modification, therapy,  indications 
NSAIDs  mild to moderate disease
 indications  techniques 
 first line of treatment  longitudinal tenotomy made in the
 techniques degenerative area 
 therapy  strip the anterior Achilles tendon with a
 physical therapy with large suture to free any adhesions
eccentric training        o open excision of degenerative tendon with tubularization
 indications 
 moderate to severe disease
 modalities (iontophoresis,
phonophoresis, and  outcomes 
 70% to 100% successful
ultrasound)
 shoewear o tendon transfer (FHL, FDL, or PB) 
 heel lifts  indications 
 cast or removable boot  degeneration of >50% of the Achilles
(severe disease) tendon
 outcomes   >55 years of age
 nonoperative management is 65%  MRI evidence of diffuse tendon
to 90% successful thickening without a focal area of disease
o glyceryl trinitrate patches, prolotherapy, and aprotinin  subacute rupture in the setting of prior
injections  achilles tendinopathy 
 indications o
 evolving indications due to lack of
evidence at this time
ptti  o tenosynovectomy
o ankle foot orthosis  indications
  indications  indicated in stage I disease if
 initial treatment for stage II, III, and immobilization fails
IV  o FDL transfer, calcaneal osteotomy, TAL, ± forefoot correction
 also for patients who are not osteotomy ± spring ligament repair ± lateral column lengthening
operative candidates, ± medial column arthrodesis ± PTT debridement         
sedentary/low demand (age > 60-
70)  
 technique  indications
 AFO family of braces (Arizona,  stage II disease
molded, articulating)   lateral column lengthening for talonavicular
 AFO found to be most uncoverage
 medial column arthrodesis if deformity is at
effective    naviculocuneiform joint
 want medial orthotic post to  contraindications 
support valgus collapse  hypermobility
 Arizona brace is a molded  neuromuscular conditions
leather gauntlet that  severe subtalar arthritis
provides stability to the  obesity (relative)
tibiotalar joint, hindfoot, and  age >60-70 (relative)
longitudinal arch    o first TMT joint arthrodesis, calcaneal osteotomy, TAL ± lateral
o immobilization in walking cast/boot for 3-4 months 
column lengthening ± PTT debridement 
 indications  indications
 first line of treatment in stage I  stage II disease with 1st TMT
disease hypermobility, instability or arthritis 
o custom-molded in-shoe orthosis o isolated subtalar arthrodesis
 indications   indications
 stage I patients after a period of  absence of fixed forefoot deformity
immobilization  contraindications 
 stage II patients   fixed forefoot supination/varus 
 technique   otherwise will overload lateral
 medial heel lift and longitudinal border of foot
arch support   joint hypermobility
 medial forefoot post o hindfoot arthrodesis      
indicated if fixed forefoot  indications 
 stage III disease 
 varus is present   typically triple arthrodesis
 UCBL with medial  stage II disease with severe subtalar
arthritis
posting   subtalar and talonavicular arthrodesis can
be considered 
o triple arthrodesis and TAL + deltoid ligament reconstruction
 indications 
 stage IV disease with passively correctable
ankle valgus
o tibiotalocalcaneal arthrodesis
 indications 
 stage IV disease with a rigid hindfoot,
valgus angulation of the talus, and tibiotalar
and subtalar arthritis
o
 o gastrocnemius recession
Plantar Fasciitis o pain control, splinting & therapy (stretching) programs  indications
 indications   no clear indications established
 first line of treatment o surgical release with plantar fasciotomy
 modalities   indications 
 plantar fascia-specific stretching  perisistent pain after 9 months of failed
and Achilles tendon stretching conservative measures
 anti-inflammatories or cortisone  outcomes
injections  complications common and recovery can
 corticosteroid injections can be protracted
lead to fat pad atrophy or o surgical release with plantar fasciotomy and distal tarsal tunnel
plantar fascia rupture decompression
 foot orthosis  indications 
 examples include  concomitant compression neuropathy (tibial
cushioned heel inserts, pre- nerve in tarsal tunnel)
fabricated shoe inserts,  technique 
night splints, walking casts  open procedure must be completed
 short leg casts can be used  outcomes 
for 8-10 weeks  success rates are 70-90% for dual plantar
  outcomes fascial release and distal tarsal tunnel
 pre-fabricated shoe inserts shown decompression
to be more effective than custom o
orthotics in relieving symptoms
when used in conjunction with
achilles and plantar fascia
stretching 
 dorsiflexion night splint most
appropriate for chronic plantar
fasciitis 
 a non-weight bearing, plantar
fascia specific stretching program
is more effective than weight
bearing Achilles tendon stretching
programs
 stretching programs have equally
successful satisfaction outcomes
at 2 years 
o shock wave treatment
 indications
 second line of treatment
 chronic heel pain lasting longer
than 6 months when other
treatments have failed 
 FDA approved for this
purpose
 technique 
 painful for patients
 outcomes 
 efficacious at 6 month followup

Adult Hallux Valgus  o surgical correction

o shoe modification/ pads/ spacers/orthoses  indications 
 indications  when symptoms present despite shoe
  first line treatment modification 
 orthoses more helpful in patients with pes  do not perform for cosmetic reasons alone
planus or metatarsalgia  technique 
  soft tissue procedure
 indicated in very mild disease in
young female (almost never)
 distal osteotomy
 indicated in mild disease (IMA < 13)
 proximal or combined osteotomy
 indicated in more moderate disease
(IMA > 13)
 1st TMT arthrodesis 
 arthritis at TMT joint or instability 
 fusion procedures
 indicated in severe
deformity/spasticity/arthritis   
 MTP resection arthroplasty
 only indicated in elderly patients
with low functional demands
o
 Juvenile and  o surgical correction
Adolescent Hallux o shoe modification  indications 
valgus  indications   best to wait until skeletal maturity to
 pursue nonoperative operate 
management until physis closes  can not perform proximal metatarsal
osteotomies if physis is
open (cuneiform osteotomy OK)
 surgery indicated in symptomatic patients
with an IMA > 10° and HVA of > 20°
 consider double MT osteotomy in
adolescent patients with increased
DMAA 
 technique 
 soft tissue procedure alone not successful
 o similar to adults if physis is closed (except in severe deformity
DJD & Hallux Rigidus o joint debridement and synovectomy
o NSAIDS, activity modification & orthotics         indications
 indications   patients with acute osteochondral or
chondral defects
 grade 0 and 1 disease 
 activity modifications o dorsal cheilectomy           
 avoid activities that lead to  indications  
excessive great toe dorsiflexion  grade 1 and 2 disease 
 types of orthotics   select patients with grade 3 disease may
 Morton's extension with stiff foot benefit from cheilectomy
plate is the mainstay of  pain with terminal dorsiflexion is an
indicator of good results with dorsal
treatment     
cheilectomy
 stiff sole shoe and shoe box
 shoe wear irritation from dorsal prominence
stretching may also be used
and pain (ideal candidate)
 contraindicated when pain located in the
mid-range of the joint during passive motion
 technique 
 remove 25-30% of the dorsal aspect of the
metatarsal head along with dorsal
osteophyte resection
 the goal of surgery is to obtain 70-90% of
dorsiflexion intraoperatively
o Moberg procedure (dorsal closing wedge osteotomy of the
proximal phalanx)
 indications 
 runners with reduced dorsiflexion (60° is
needed to run)
 failure of cheilectomy to provide at least 30
to 40 degrees of motion   
 technique
 increases dorsiflexion by decreasing the
plantar flexion arc of motion
o Keller Procedure (resection arthroplasty) 
  indications 
 elderly, low demand patients with
significant joint degeneration and loss of
motion
 contraindicated in patients with pre-existing
rigid hyperextension deformity of 1st MTP
joint
 technique 
 involves removing the base of the first
proximal phalanx
 risk of hyperextension (cock-up deformity),
weakness with push-off, and transfer
metatarsalgia (decreased with capsular
interposition)
o MTP arthroplasty  
 indications
 indications controversial
 technique
 capsular interpositonal arthroplasty gaining
popularity
 silicone implants are not recommended due
to poor long-term results
 outcomes 
 silicone implants may have a good short
term satisfaction rate
 osteolysis and synovitis cause mid to long
term pain and joint destruction
o MTP joint arthrodesis         
 indications 
 grade 3 and 4 disease (significant joint
arthritis)
 most common procedure for hallux rigidus
 outcomes 
 70% to 100% fusion rate
  15% of patients experience degeneration of
IP joint after surgery (mostly asymptomatic)
o MTP joint arthrodesis with structural bone graft   
 indications for structural bone graft 
 1st MT shortening that cannot be
adequately rebalanced with a lesser
metatarsal osteotomy (usually shortening >
5 mm) 
 most commonly seen with failed
MTP arthroplasty
 significant proximal phalanx bone loss with
inadequate remaining bone for fixation
without compromising IP joint, 
 1st MT shortening with loss of medial
support of the 2nd toe predisposing to
varus at the 2nd MTP joint. 
o
Sesamoid Injuries of o partial or complete sesamoidectomy
the Hallux o NSAIDs, reduced weightbearing, activity modification,  indications 
orthoses  nonoperative management fails after 3-12
 indications  months   
 indicated as first line of treatment  technique (see below)
o short leg cast with toe extension o autologous bone grafting 
 indication   indications 
 acute fracture (controversial)  nonunion or  fracture
o shaving keratotic lesion o dorsiflexion osteotomy
 indications   indication 
 keratotic lesion present increasing  plantar-flexed first ray with sesamoid injury
pressure on sesamoids o
Turf Toe  o surgical repair 
o rest, NSAIDS, taping, stiff-sole shoe or walking boot   indications (usually Grade III injuries) 
 indications   failed conservative treatment
 nonoperative modalities indicated  retraction of sesamoids
 in most injuries (Grade I-III)  fracture of sesamoids with diastasis
 technique   traumatic bunions
 early icing and rest  loose fragments in the joint
 taping not indicated in acute phase  hallux toe deformity
due to vascular compromise with  technique 
swelling  medial plantar incision
 stiff-sole shoe or rocker bottom  repair or excision of sesamoid depending
sole to limit motion on fragmentation
 more severe injuries may require  headless screw or suture repair of
walker boot or short leg cast for 2- sesamoid fracture
6 weeks  joint synovitis or osteochondral defect often
 physiotherapy  requires debridement or cheilectomy
 progressive motion once the injury  abductor hallucis transfer may be required
is stable if plantar plate or flexor tendons cannot be
restored
 outcomes 
 immediate post-operative non-weight
bearing 
 progressive ROM and physiotherapy
 expected return to sport 3-4 months
o
Hallux Varus  o lateral closing wedge osteotomy
o shoe modifications to accommodate the deformity  indications
 indications  overcorrection of proximal/distal metatarsal
 flexible, longstanding and osteotomy, or proximal phalangeal
asymptomatic deformities osteotomy
 patient preference  techniques
 modalities  revision osteotomy to re-establish
 wider and more flexible toe box alignment
shoes  consider release of scar tissue and repair of
 padding boney prominences the lateral ligaments 
 outcomes o tendon transfer with medial release
 mild flexible and stable deformities  indications
are usually well tolerated   flexible first MTP joint deformities
o taping or splinting the deformity   techniques
  indications  aDDuctor hallucis tendon re-attachment
 early post-operative varus with medial release
deformities after hallux correction   may be difficult in cases of previous
surgery McBride-type surgery
 modalities  aBDuctor hallucis tendon transfer on the
 frequent taping and follow-up base of the lateral base of proximal phalanx
 duration should be maintained for  combined with the reattachment or
up to 3 months or until soft-tissues reefing of the conjoined tendon in
have healed the web space
 outcomes
 may correct deformity if initiated  transfer or EHL or EHB, medial release,
within the first few weeks from with or without IP joint arthrodesis
surgery  transfer portion of EHL or EHB
under the transverse
intermetatarsal ligament to the distal
metatarsal neck (from lateral to
medial)
o first MTP arthrodesis   
 indications 
 absolute
 fixed (not passively correctable) first
MTP joint with significant deformity
and non-functioning hallux
 painful joint arthritis
 relative
 excessive medial eminence
resection beyond tibial seasmoid
sulcus
o
Claw Toe  o EDB tenotomy, EDL lengthening, FDL flexor-to-extensor transfer
o taping and shoe modification   (Girdlestone) 
 indications   indications 
 first line of treatment  painful, flexible deformities without
 techniques  contractures
  provide adequate plantar padding  ulcerations caused by shoe wear
using metatarsal and/or crest pads o Girdlestone (above), MTP capsulectomy, and proximal phalanx
or orthotics to offload plantarly- head and neck resection
subluxed metatarsal heads  indications 
 wear a shoe with a high toe box  fixed contracture
 use a sling to hold the proximal o Girdlestone and distal MT shortening osteotomy (Weil lesser MT
phalanx parallel to the ground
osteotomy) 
 indications 
 claw toe deformity of all four lesser toes
 technique 
 oblique shortening osteotomy
 translates metatarsal head proximal and
plantar
o Isolated FDL tenotomy 
 indications 
 flexible deformity in a diabetic patient with
tip-of-toe ulceration without evidence of
infection
o
Hammer Toe o shoes with high toe boxes, foam or silicone gel sleeves o flexor tendon (FDL) to EDL tendon transfer
 indications   indications 
 pain and or corns on dorsal PIP  flexible deformity that has failed
nonoperative management
o PIP resection arthroplasty +/- tenotomy and tendon transfers
 indications 
 rigid deformity that has failed nonoperative
management     
o Girdlestone procedure with FDL to EDL transfer
 indications 
 MTP involvement
 similar to claw toe treatment
o EDL Z-lengthening or tenotomy
 indications
 mild MTP hyperextension
 o EDL Z-lengthening and dorsal capsular release
 ndications 
 moderate to severe MTP hyperextension
o PIPJ arthrodesis
 indications 
 an option in rigid deformity
 outcomes 
 high nonunion rate
o treat concurrent forefoot deformities 
 correct hallux valgus (for 2nd hammer toe) 
 arthrodesis for severe hallux valgus
 amputation for severe hallux valgus
touching 3rd toe 
 indications 
 elderly
 poor health 
 does not want hallux
reconstruction
o
MTP Dislocations  o distal oblique shortening MT osteotomy (Weil procedure)  
o taping, shoe modification, metatarsal pads, Budin splint,  indications 
and NSAIDS   significant pain and loss of function
 indications  fixed deformity 
 first line of treatment o plantar plate repair
 will not correct deformity   performed with metatarsal osteotomy
 sutures passed through distal plantar plate and
then through drill holes in proximal phalanx
o flexor to extensor tendon transfer
 FDL split and brought over top of proximal phalanx
to stabilize joint
o EDB transfer under intermetatarsal ligament
o
Bunionette Deformity  
o NSAIDS, shoe wear modification, orthotics, keratosis o lateral condylectomy
padding, callous shaving  indications
 indications   symptomatic Type I deformities 
 indicated as first-line treatment of  technique 
all types  resection of lateral third of the 5th MT head
 asymptomatic deformities  combine with tightening of lateral MTP joint
 techniques  capsule
 semi-rigid shoe inserts  outcome 
 wide based shoes   does not require extended period of
 stretching the forefoot of existing immobilization
shoes
 outcomes  o distal metatarsal osteotomy 
 75-90% success rate  indications 
 long-standing or severely
symptomatic Type I deformity
 Type 2 and 3 deformities if IMA is < 12
degrees 
 technique 
 different techniques described 
 chevron-medializing osteotomy
(most common)
 distal transverse osteotomy
 peg-and-slot type osteotomy
 stepcut osteotomy
 better stability of fragments with internal
fixation (e.g. K-wire or screw)
 may be combined with distal condylectomy
and tightening of lateral capsule
 outcomes 
 chevron osteotomy is biomechanically the
strongest construct compared to the other
proximal osteotomies
o oblique diaphyseal rotational osteotomy 
 indications 
 symptomatic Type 2 and 3 if IMA is > 12
 degrees    
 technique 
 shave plantar aspect 5th MT head if plantar
callosity present
 proximal osteotomy should be avoided due
to poor blood supply in this region of the
metatarsal
 fixation achieved with screw
 outcomes
 may produce 5th MT shortening 
o metatarsal head resection
 indications 
 salvage procedure only
 leads to unacceptable instability of MTP
joint
o
  o metatarsophalangeal arthrotomy with removal of loose bodies
 2 o activity limitations, NSAIDS, immobilization  indications
0%  indications  very rarely indicated
Freiberg's Disease  early stage of disease  only if extensive nonoperative management
 technique fails
 short leg walking cast or boot for o dorsal closing-wedge osteotomy 
4-6 weeks  indications 
 can be used if symptoms  dorsal disease involvement of bone and
are severe and do not cartilage
improve with orthotics
 stiff-soled shoe with MT bars or o DuVries arthroplasty (partial MT head resection)   
pads  indications
 typically used after period  severe stage 4 or 5 disease
of casting  plantar cartilage is not sufficient to
reconstruct joint
 can consider adding capsular interposition
after joint debridement
o
Osteochondral o immobilization and non-weight bearing o arthroscopy with removal of the loose fragment, debridement
Lesions of the Talus indications  and marrow stimulation   
acute injury  indications 
nondisplaced fragment with
incomplete fracture  chronic lesions 

 size < 1 cm
 displaced smaller fragment with minimal
bone on the osteochondral fragment (poor
healing potential)
o retrograde drilling and/or bone grafting   
 indications 
 size > 1 cm with intact cartilage cap
o osteochondral grafting (osteochondral autograft transplantation,
autologous chondrocyte implantation, bulk allograft) 
 indications 
 size > 1 cm and displaced lesions, shoulder
lesions
 salvage for failed marrow stimulation or
drilling
 contraindications
 diffuse ankle arthritis
 bipolar kissing lesions
 advanced osteonecrosis of the talar done
o
Midfoot Arthritis  o midfoot arthrodesis, +/- TAL, +/- hindfoot realignment   
o NSAIDS, activity modification, orthotic/bracing  indications 
 indications   failure of non operative management
 first line of treatment  outcomes
 modalities   midfoot joints are non-essential joints 
 steroid injections under  arthrodesis results in close to normal foot
radiographic guidance function 
 can be diagnostic and o Achilles tendon lengthening/hindfoot realignment
therapeutic   may need to be done concomitantly
 orthotics   o
  cushioned heel
 longtidunal arch supports
 stiff sole with a rocker
bottom

 o surgical debridement, antibiotics, local wound care,

 24 o factors important in deciding a treatment plan contact casting     
0% include  indications 
Diabetic Foot Ulcers angiopathic vs. neuropathic grade 3 or greater ulcers should undergo
deep vs. superficial I&D with antibiotic treatment before casting
+/- osteomyelitis, antibiotics based on outcomes 
bone biopsy culture sensitivities  high rates of associated osteomyelitis if
+/- pyarthrosis bone is able to be probed, or is exposed at the base of the ulcer
Nonoperative  o ostectomy +/- TAL
o shoe modification indications
indications  bony prominence causing internal pressure
prevention when signs of potential technique 
ulcers are present TAL indicated if tight Achilles       
includes deep or wide shoes, custom several studies have shown TAL to
insoles, rocker bottom soles, etc. be effective to help heal and prevent recurrence of plantar forefoot
of the available shoe only modifications,
ulcers   
rocker sole shoes best reduce the plantar pressure on the
o partial calcanectomy +/- TAL  
forefoot 
indications 
medicare will cover modifications and
large heel ulcers with associated
custom shoes/insoles yearly  calcaneal osteomyelitis
o wound care outcomes 
indications preserves limb length and decreases
first line of treatment morbidity compared to higher level amputations
goals of wound care and dressings 
o Syme amputation 
provide moist environment
indications 
absorb exudate
forefoot gangrene and a palpable posterior
act as a barrier
tibial artery pulse
off-load pressure at ulcer
o total contact casting (TCC)  o Keller resection arthroplasty 
 indications  indications 
gold standard for mechanical IPJ plantar neuropathic ulcer with
relief plantar ulcerations    hypomobile/stiff MTPJ that has failed total contact casting
contraindications  o
absolute 
infection
relative 
marginal arterial supply to
affected area
patients unable to comply
with cast care
patients unable to tolerate
a cast (cast claustrophobia)
outcomes 
if ulcer recurs, it is typically 3-4
weeks after cast removal 

Diabetic Charcot  o resection of bony prominences (exostectomy) and TAL 

Neuropathy o total contact casting, shoewear modifications,  indications 
medications         "braceable" foot with equinus deformity and
 indications  focal bony prominences causing skin
 first line of treatment breakdown
 technique   technique  
 contact casting   goal is to achieve plantigrade foot that
 casts changed every 2-4 allows ambulation without skin compromise
weeks for 2-4 months o deformity correction, arthrodesis +/- osteotomies   
 orthotics   indications 
 Charcot restraint orthotic  severe deformity that is not "braceable"
walker (CROW) boot can  outcomes 
be used after contact  very high complication rate (up to 70%)
casting    o amputations
 shoe modifications   indications 
 in Eichenholtz stage 3  failed previous surgery (unstable
arthrodesis)
 double rocker shoe  recurrent infection
modifications will best  technique 
reduce risk for ulceration at  goal is for a partial or limited amputation if
the plantar apex of the vascularity allows
deformity  o
 medications 
 bisphosphonates
 neuropathic pain
medications
 antidepressants
 topical anesthetics
 outcomes 
 75% success rate

Acquired Spastic  o Achilles tendon lengthening with split anterior tibialis tendon
Equinovarus o physical therapy, injections, orthoses transfer (SPLATT)
Deformity  indications   indications 
  as first line of treatment  fixed contractures persist after the period of
 modalities  neurologic recovery and are not braceable.
 therapy   functional deficits 
 focus on stretching and  skin problems secondary to deformity
strengthening,  technique 
maintenance of joint range  equinus deformity is treated with
of motion lengthening of the Achilles tendon
 injections   varus deformity is treated with a split
 phenol blocks anterior tibialis tendon transfer (SPLATT) 
and botulinum toxin o osteotomies and fusions
injections are used  indications 
 AFO   recurrence of deformity despite proper soft
 should be used while the tissue procedures
patient is in bed or o
wheelchair

Interdigital (Morton's)  o neurectomy 

Neuroma o wide shoe box with firm sole and metatarsal pad   indications 
 indications   failure of nonoperative management 
 first line of treatment  techniques
 outcomes  dorsal or plantar approach (dorsal most
 results are unpredictable common) 
 approximately 20% of  neurectomy with nerve burial (bury proximal
patients will have complete stump within intrinsic muscles)
resolution of symptoms  transverse intermetatarsal ligament
 adding anti-inflammatory release 
medications rarely provide any o
benefit
o corticosteroid injection
 indications
 symptomatic benefit 
 modality
 usually approached dorsal after
isolating the neuroma with
palpation or ultrasound
 outcomes
 evidence for its effectiveness is
weak
 suggested to provide symptomatic
benefit in short term randomized
control studies

 o surgical release of tarsal tunnel

Tarsal Tunnel o lifestyle modifications, medications  indications
Syndrome  indications    after 3-6 months of failed conservative
 usually ineffective management and
 medications   compressive mass (ganglion cyst)
 anti-inflammatory medications identified
 SSRIs have been used  positive EMG
 bracing   reproducible physical findings
 orthosis or foot wear changes to  outcomes 
 best results following surgery are in cases
 address alignment of hindfoot where a compressing anatomic
 can try a period of short-leg cast structure (ganglion cyst) is identified and
 removed 
 traction neuritis does not respond as well to
surgery
o
Deep Peroneal Nerve  o surgical release of DPN by releasing inferior extensor
Entrapment o shoe modifications retinaculum and osteophyte / ganglion resection
 indications   indications 
 first line of treatment  failure of nonoperative treatment
 techniques   symptoms of RSD are a contraindication to
 NSAIDs release
 PT (if ankle instability contributing)  outcomes 
 injection  80% satisfactory
 well padded tongue on shoe o
 alternative lacing
configurations   
 full length rocker-sole steel shank
 night splint (to prevent natural
tendency for ankle to assume
plantar flexion)
 diuretic if chronic peripheral edema
is implicated
THA revision  Femoral revision 
o primary total hip arthroplasty components 
 indications 
 minimal metaphyseal bone loss, Paprosky I
o uncemented extensively porous-coated long-stem prosthesis (or porous-coated/grit blasted combination) or modular tapered
stems       
 indications 
 most Paprosky II and IIIa defects; Paprosky IIIb (modular fluted tapered stem)
 outcomes 
 95% survival rate at 10-years
o femoral impaction bone grafting 
 indications 
 large ectactic canal and thin cortices 
 Paprosky IIIb and IV defects 
 outcomes 
 most common complication is stem subsidence
o allograft prosthetic composite (APC) 
 indications
 Paprosky IIIb and IV defects
o endoprosthetic replacement (EPR)   
 indications
 massive bone loss with a non-supportive diaphysis
 Paprosky IIIB and IV defects
o cemented stems 
 indications 
 irradiated bone
 elderly
 low-demand patients
 outcomes 
 high failure rate
 Acetabular revision 
o porous-coated hemisphere cup or jumbo secured with screws     
 indications 
 at least 50% of bone stock present to support cup
 disadvantage 
 jumbo cup may disrupt posterior column with additional bone reamed
 dislocation
o porous-coated hemispherical cup with acetabular augments
 indications 
 bone loss (Paprosky defects Type IIB-C and IIIA-B)
 outcomes 
 2 year survivorship 94%-100%
 5 year survivorship 92%-100%
  10 year survivorship 92%
o reconstruction cage with structural bone allograft     
 indications 
 rim is incompetent (<2/3 of rim remaining), <50% of bone stock present
 outcomes 
 allograft failure is the most common complication 
 high failure rate (40-60%) without reconstruction cage due to component migration after graft resorption
o custom triflange cup    
 indications 
 pelvic discontinuity
o cemented acetabular components
 can cement a liner by itself or into a well fixed cup
o liner options
 e.g. face changing, oblique, lipped, offset, contrained, dual mobility, etc. 
 Combined revision 
o femoral head and polyethylene exchange
 indications 
 eccentric wear of the polyethylene with stable acetabular and femoral components 
 acute infectiontrunnionosis
 outcomes
 hip instability is the most common complication of isolated liner exchange   
o conversion from a hip arthrodesis 
 indications 
 low back and knee pain as a result of arthrodesis
 outcomes 
 implant survival greater than 95% at 10 years
 competence of abductor and gluteal musculature is predictive of ambulatory success
 improved ipsilateral knee and back pain
 Revision without changed modular or nonmodular components 
o ORIF periprosthetic fracture 
 indications 
 fracture with stable components
 o psoas release 
 indications 
 painful psoas with clinical signs of impingement and improvement with lidocaine injection
 can be completed arthroscopically
o heterotopic bone excisions 
 indications 
 mature heterotopic bone formation causing pain and restricted range of motion
o
Osteonecrosis o bisphosphonates core decompression with or without bone grafting
 indicated for precollapse AVN (Ficat  indications 
stages 0-II)   for early AVN, before subchondral collapse
 trials have shown that alendronate occurs
prevents femoral head collapse in  reversible etiology
osteonecrosis with subchondral  technique
lucency   traditional method
 However, other studies have also  drill an 8-10  mm hole through the
shown no benefit of preventing subchondral necrosis
collapse with bisphosphonates  alternative method
 pass a 3.2 mm pin into the lesion
two to three times for
decompression
 relieves intraosseous hypertension equals
less pain
 stimulates a healing response via
angiogenesis
o rotational osteotomy
 indications
 only for small lesions (<15%) in which the
lesion can be rotated away from a weight
bearing surface 
 technique
 typically performed through
intertrochanteric region
 for medial disease
 perform varus rotational osteotomy
  for anterolateral disease 
 perform valgus flexion osteotomy
 outcomes 
 reported success rate of 60% to 90%,
mainly in Japan
 distorts the femoral head making THA more
difficult
o curettage and bone grafting through Mont trapdoor technique or
Merle D'Aubigne lightbulb technique
 indications 
 preferably pre-collapse
 technique 
 lightbulb - through the cortex of the femoral
neck-head junction to access the necrotic
area of the femoral head and place bone
graft
 trapdoor - through articular surface
o vascularized free-fibula transfer
 indications
  for both pre-collapse and collapsed AVN in
young patient
 reversible etiology preferred
 technique
 remove the necrotic area with large core
hole
 fibular strut is placed under subchondral
bone to help prevent collapse or tamp up
small areas of collapse
 outcomes 
 some centers demonstrating 80% success
at 5 to 10-year follow-up
 less predictable in patients >40
 complications 
  related to donor site morbidity
 sensory deficit
  motor weakness
 FHL contracture
 tibial stress fracture from side graft
is taken
o total hip replacement   
 indications 
 younger patient with crescent sign or more
advanced femoral head collapse, +/-
acetabular DJD
 irreversible etiology (chronic steroid use)
 patients >40 with large lesions
 techniques 
 cementless cup and stem
 care must be taken while preparing the
femur as there are high rates of femoral
canal perforation   
 outcomes 
 in young patients with osteonecrosis, there
is a higher rate of linear wear of the
polyethylene liner and a higher rate of
osteolysis than compared to older patients
who have THA for osteoarthritis 
 provides good pain relief and function
 most reliable means to provide pain relief
and immediate return of function 
o total hip resurfacing
 indications 
 in advanced DJD with small, isolated focus
of AVN
 requires adequate bone to support
resurfacing component
 contraindicated in underlying disease
process or chronic steroid use causing AVN
(poor bone quality) and renal disease
 (metal ions from metal-on-metal implant)
 outcomes 
 medium-term follow-up showing problems
with acetabular erosion and pain
o hip arthrodesis
 indications 
 only consider in the very young patient in
a labor intensive occupation
o
Adult Dysplasia of the  hip arthroscopy
Hip o indications 
 controversial 
 adjunct procedure to PAO for enhanced visualization and management of chondral, labral and proximal femoral cam-
type lesions 
 contraindicated in the setting of moderate to severe dysplasia
o outcomes  
 chondral and labral pathology is a sequelae of osseous instability and may recur or progress if underlying pathology is
not corrected  
 associated with accelerated progression of arthritis, hip subluxation, less functional improvement, as well as
increased risk of surgical failure and reoperation 
 periacetabular osteotomy (PAO)
o indications         
 symptomatic dysplasia in an adolescent or adult with a concentrically reduced hip and congruous joint space 
 preserved range of motion 
 intraoperative dynamic testing of hip motion is needed to determine the need for femoral osteotomy  
 minimum of 90° flexion and 15° internal rotation to prevent FAI 
o advantages 
 provides hyaline cartilage coverage
 preserved integrity of the posterior column, which allows patients to weight bear as tolerated postoperatively 
 large multidirectional corrections 
 preserves external rotators
 delays need for arthroplasty
o outcomes 
 reliably improves radiographic parameters and symptomatology
  92% survivorship at 15 years in avoiding THA 
 salvage pelvic osteotomy (Chiari, Shelf)
o indications 
 unreduced hip
 recommended for patients with inadequate femoral head coverage and an incongruous joint (a salvage procedure)
o outcomes 
 84% survivorship at 17 years with advanced OA as an endpoint 
 advanced DDH and asphericity of the femoral head associated with poor outcomes 
 hip resurfacing
o indications 
 can be used for Crowe type I or II disease
o outcomes 
 unable to address leg-length discrepancy 
 10% revision rate at 6 years 
 higher revision and complication rate with hip resufracing in patients with DDH compared to general population 
 total hip arthroplasty (THA) 
o indications 
 treatment of choice for patients with end-stage OA secondary to dysplasia 
 may need small acetabular components 
o outcomes  
 improves Harris Hip scores and pain
 outcomes for Crowe I and II patients are in similar to those of THA for primary OA in the short term  
 revision rates for Crowe III and IV are higher than non-dysplastic hips 
 long term follow up demonstrates a higher revision rate for THA in dysplastic hips 
 increased complication profile: infection, instability and neruovascular injury  
 risk of sciatic nerve injury if limb length changed by >4cm   
 may need to perform femoral shortening (trochanteric or subtrochanteric)   
o
Periprosthetic tka  nonoperative 
femur o casting or bracing
 indications 
 nondisplaced fractures with stable prosthesis
 operative 
o antegrade intramedullary nail
 indications 
 supracondylar fracture proximal to the femoral component (Su Type I)
o retrograde intramedullary nail 
 technical considerations
 at least 2 distal interlocking screws
 use end cap to lock most distal screw if available
 femoral component may cause starting point to be more posterior than normal and lead to hyperextension at
the fracture site
 nail must be inserted deep enough (not protrude) to not abrade on patella/patellar component
 indications 
 intact/stable prosthesis with open-box design to accommodate nail
 fracture proximal to femoral component (Su Type I)
 fracture that originates at the proximal femoral component and extends proximally (Su Type II) 
o ORIF with fixed angle device 
 indications 
 intact/stable prosthesis
 Lewis-Rorabeck II or Su Types I or II (described above) unable to accommodate intramedullary device
 fracture distal to flange of anterior femoral component (Su Type III) 
 techniques 
 condylar buttress plate (non-locking) 
 does not resist varus collapse
 locking supracondylar / periarticular plate   
 polyaxial screws allow screws to be directed into best bone before locking into plate, and can avoid
femoral component
 blade plate / dynamic condylar screw 
 difficult to get adequate fixation around PS implants
 complications 
 nonunion   
 increased risk in plating via extensile lateral approach compared with submuscular approach 
 malunion
 increased risk with minimally-invasive approach/MIPO
 o revision to a long stem prosthesis 
 indications 
 loose femoral component
 Lewis-Rorabeck III or Su Type III (described above) with poor bone stock
o distal femoral replacement   
 indications 
 elderly patients with loose (Su type III) or malpositioned components and poor bone stock 
 advantages 
 immediate weight-bearing
 decreased operative time of procedure
o
Periprosthetic tka  nonoperative
Tibia o casting or bracing
 indications
 nondisplaced fracture with stable prosthesis
 operative
o ORIF
 indications
 unstable fracture with stable prosthesis
o long-stem revision prosthesis     
 indications
 displaced fractures with loose tibial component
o
Periprosthetic tka  nonoperative
patella o casting or bracing in extension   
 indications 
 stable implants with intact extensor mechanism 
 non-displaced fractures
 operative
o indications
 loose patellar component   
 extensor mechanism disruption   
 o techniques (indications for each have not been clearly defined)
 ORIF with or without component revision   
 partial patellectomy with tendon repair
 patellar resection arthroplasty and fixation
 total patellectomy
o
 o knee immobilizer x6 weeks 
 1  indications  o direct repair with suture
0%  partial quadriceps tendon  indications 
TKA Extensor rupture     patellar tendon avulsion < 30%
Mechanism Rupture   complete quadriceps tendon rupture with
adequate soft tissues
o primary repair and augmentation with graft 
 indications 
 complete laceration of patellar tendon with
adequate patellar bone stock
o extensor mechanism reconstruction 
 indications 
 complete laceration of patellar tendon
without adequate patellar bone stock and
deficient soft tissues
 Chronic extensor mechanism (patella or
quadricep tendon) disruption
o
TKA Stiffness  o arthroscopic lysis of adhesions with manipulation under
o manipulation under anesthesia  anesthesia
 indications  indications
  flexion <90 degrees within first 12  persistent late stiffness
weeks of operation (timing is o revision total knee arthroplasty
controversial)           indications
 over aggressive  identifiable technical cause for stiffness
manipulation o
 fracture
  extensor
mechanism
disruption
 contraindications 
 stiffness >3 months
postoperatively 
 manipulation associated with
greater risk and lower benefit
