Anatomy and Orthopaedic Surgery

Orthopaedic surgery is the branch of medicine concerned with the preservation of the musculoskeletal system. Therefore the goal is to treat diseases and injuries; correct deformities; and make surgical repairs to bone, cartilage, muscles, tendons, ligaments, synovia, bursa, fascia, and nerves of the upper and lower limbs, shoulder, spine, and pelvis. A general list of the types of surgery performed on these tissues is presented in Table 8-1 .

Table 8-1Orthopaedic Procedures *

Prefixes/Roots: Tissue Types Procedures
Osteo- (bone) 2, 4, 5, 6, 7, 8
Myo- (muscle) 2, 3, 4, 5, 6, 7
Tendo- or teno- (tendon) 3, 4, 5, 6, 7, 10
Desmo- (ligament) 5
Syndesmo- (ligament) 6, 7
Fascio- or fascia- (fibrous bands) 4, 5, 6, 7, 9
Burs- (bursa, sac, pouch) 1, 4, 6, 9
Spondylo- (spine) 3, 6
Myelo- (spinal cord, meninges, bone marrow) 1, 5, 6, 9
Lamin- (lamina) 4, 6
Rachio- (spine) 1, 6
Neur- (nerves) 4, 5, 6, 7, 10
Arthro- (joint) 1, 2, 3, 4, 6, 7, 9, 10, 11
Chondro- (cartilage) ( Fig. 8-2 ) 2, 4, 6
Synov-(synovium) 4
Capsul- (capsule) 3, 4, 5, 6, 7
Condyl- (condyle) 4, 6
Aponeur- (fascial bands) 4, 5, 6

* The left column (prefixes/roots) indicates the anatomy; corresponding numbers in the right column (procedures) describe the types of surgery performed on those tissues.

1.centesis: surgical puncture; perforation or tapping with aspirator, trocar, or needle. 2.clasis: surgical fracture or refracture of bones and other tissue by crushing; refracture of bone in malposition. 3.desis: binding, fixation by means of suture (tendon) or fusion (joints); not to include spine. 4.ectomy: excision of organ or part. 5.orrhaphy: to suture or sew. 6.otomy: surgical incision into a part or organ; cut into. 7.plasty: to form, mold, or shape; surgical shaping or formation. 8.synthesis: putting together, composition, surgical fastening of ends of fractured bones by sutures, rings, plates, or other mechanical means. 9.gram: injection of contrast media for x-ray examination. 10.lysis: dissolution of tissue; decomposition, freeing of scar or adhesions. 11.oscopy: to view by a scope.

Orthopaedic surgery encompasses an overwhelming number of procedures that attempt to alter normal or abnormal anatomic structures. The four-volume Campbell’s Operative Orthopedics is one of the textbooks of this surgical specialty. Many of the new terms are briefly described in this chapter.

The anatomy of the musculoskeletal system is defined here to correlate with the surgery on specific tissue by anatomic area. Numerous figure illustrations are provided to enhance the understanding of anatomic structures. An associated surgical word list is included at the end of the chapter.

Osteo- (Bone)

Anatomy of Bone

Osseous tissue (bone) constitutes the majority of the skeletal framework consisting of 206 bones of various sizes and shapes that are living, hard connective tissue composed of organic (cells and matrix) and inorganic (mineral) components with submicroscopic laminations of protein and crystal layers. The matrix contains a framework of collagenous fibers that are impregnated with the mineral components, mainly in the form of apatite crystals, which give the quality of rigidity to bone. Another function of bone is its hematopoietic ability.

If all of the mineral were removed from the bone, the resulting structure would be firm and pliable and have the exact shape of the mineralized bone. The process of calcification is not restricted to bones; it may occur in an amorphous form in tendons, bursae, and other tissues. Ossification is actual formation of bone tissue, which then calcifies by addition of hydroxyapatite crystals composed of calcium, phosphate, and hydroxyl ions. The term is also applied to the formation of bone in the sleeve of gristly tissue that surrounds most healing fracture. That sleeve is called callus . The following terms relate to the shape, structure, and microanatomy of bone ( Fig. 8-1 ).

  • apophysis: a tubercle of bone that contributes to its growth but is the point of strong tendon insertion and usually has a ossification center. An example is the greater trochanter.

  • articular cartilage: epiphyseal covering; thin layer of hyaline cartilage over the articular surface (ends) of bone to provide a bearing surface for joint and respond to shear and compressive forces.

  • bone marrow: an organ that functions to manufacture the formed elements of blood (hematopoiesis), including erythrocytes (red blood cells), lymphocytes and granulocytes (white blood cells), and platelets. It is a network of connective tissue filled with blood vessels that form and develop blood corpuscles and is found in the proximal epiphyses of the humeri and femora, ribs and sternum, and cancellous bone of vertebrae. Yellow bone marrow is found in the medullary cavity in adults and contains fatty marrow.

  • bone matrix: the extracellular substance of bone composed of collagenous fibers embedded in an amorphous ground substance and inorganic salts.

  • calcium: a necessary mineral that, in combination with phosphorus, forms a specific calcium phosphate (apatite crystals), which is the dense, hard material of bones and teeth. It is the most abundant mineral in the body and the skeleton serves as the main center for calcium storage. Calcium is critical in the function of muscles, nerves, blood coagulation, and heartbeat.

  • cambium layer: loose cellular inner layer of the periosteal tissue; involved in the intramembranous ossification of bone.

  • canaliculus: communicating, narrow tubular channel between osteocytes in bone.

  • cancellous bone: spongy, porous, latticelike osseous tissue.

  • condyle: prominence at the widened end of long bones that function as attachment sites for ligaments, tendons, or muscles. Two examples are the femoral condyles, the inner and outer palpable prominences of the upper knee joint.

  • cortical bone: the thick, dense outer portion of bone that surrounds the medullary (marrow) cavity; also called compact bone.

  • cut-back zone: in growing bone, the zone just metaphyseal to the growth plate, where the diameter of the bone is being narrowed.

  • cutting cone: one means of bone remodeling, cone-appearing blood vessel as seen on longitudinal microscopic section; osteoclasts can be seen absorbing bone at the head of the cone.

  • diaphysis: the thick, compact, midportion of long bones, providing strong support.

  • enchondral bone: bone that forms by replacing a cartilage precursor, either cartilage growth plate or from cartilage in fracture callus; also called cartilage bone and substitution bone.

  • endosteum: the lining of the trabecular and cortical bone that is within the medullary canal or cavity.

  • epiphysis: the bulbous growth end of a long bone, usually wider than the shaft and initially all cartilage. With growth bone forms in the center, called a secondary center of ossification . It is separated from the metaphysic by a cartilaginous disk, the physis, which is also called the epiphyseal plate or growth plate. There are two types of epiphyses:

    • pressure e.: a secondary center of ossification in the articular end of a long bone with articular elements subjected to pressure.

    • traction e.: a secondary center of ossification at the site of attachment of a tendon and subjected to traction. Contributes to bone shape (e.g., apophysis).

  • facet: a flat, platelike surface on a bone that acts as part of a joint; facets are seen in the vertebrae and form facet joints and in the subtalar joint of the ankle.

  • flat bones: bent or curved rather than flat, these bones protect viscera and other soft tissues, and include the pelvis, ribs, and shoulder blade.

  • haversian canals: one of the minute vascular canals running lengthwise in compact osteonal bone; part of an important system in transporting bloodborne material to widely separated bone cells. This transport system is composed of the haversian canals, surrounding lamellae, connecting canaliculi, and lacunae. The lateral branches of these vessels are called Volkmann canals.

  • Howship lacuna: microscopic area of bone resorption that occurs on the surface of bone, resulting from activity. Microscopically resembles a small pit on the edge of bone surface (resorption pit).

  • isthmus: narrow portion of the canal in the midshaft of a long bone.

  • lamellar bone: mature bone that results from the remodeling of immature bone into a highly organized and stress-oriented pattern of collagen.

  • line: a less prominent ridge on bone—for example, the iliopectineal line—whereas a crest is a more prominent ridge (iliac crest).

  • medullary canal: the canal in the center of a bone shaft containing soft, fatty marrow elements in adults and cancellous bone.

  • membranous bone: collagen model bone that is formed directly from the periosteum, without development of cartilage, and develops within a connective tissue membrane. An example is the skull.

  • metaphysis: the wider portion of a long bone between the diaphysis and the epiphysis. This portion of bone represents the most recently formed bone (growth zone) during the growth process. With closure of physis, it is continuous with the epiphysis.

  • ossification: process of forming bone (ossifying, adj.). Other related terms include the following:

    • osseous: general term referring to bony matter.

    • ossiferous: containing or producing bone.

    • ossific: refers to the presence of bone.

    • osteoid: refers to the uncalcified bone matrix.

  • osteoblast: a bone-forming cell; cells that produce osteoid, which is the matrix of bone, composed predominantly of type I collagen and a number of bone proteins.

  • osteoclast: bone resorbing cell; cells derived from monocellular precursors, which, under the influence of parathyroid hormone and other systemic and local substances, absorb bone. The specific microscopic region of bone resorption is called a Howship lacuna.

  • osteocyte: bone cell; osteoblastic cell that has become encased in bone matrix and has cellular extensions called canaliculi, which allow the cell to connect and communicate with other osteocytes and thereby affect bone metabolism.

  • osteonal bone: a microscopic description of bone seen in mature adults that is highly organized in response to stress-related growth. An osteon is the single unit of osteonal bone and represents a central vascular channel surrounded by layers of circumferential lamellar bone.

  • periosteum: firm, thin, two-layered fibrous outer covering of bone; outer layer contains blood vessels; inner layer contains connective tissue cells and elastic fibers. The periosteum is important for circumferential bone growth and in bone repair because of its bone-forming cells and blood vessels that supply the osteogenic layer. The nerve endings in periosteum are responsible for the sensitivity of bone in trauma. The thin layer of multipotential cells that is immediately next to the bone is called the cambium layer.

  • physis: the cartilage between the apophysis or epiphysis and the shaft of the bone. This cartilage is responsible for the longitudinal growth of the bone. Although the epiphyseal cartilage is called the growth plate, as in the previous definition, the term epiphyseal cartilage may also refer to the cartilage lining the joint; also called growth plate and epiphyseal plate. Typically divided into the following zones:

    • resting zone: zone of cartilage cells with little metabolic activity and no cell division.

    • proliferating zone: zone of cell replication where cells are stacked in longitudinal rows; also called columnar zone.

    • hypertrophic zone: zone where cells become larger.

    • zone of provisional calcification: calcium appears in matrix, and beyond this point, invading blood vessels appear with bone cells on surface of calcified cartilage.

  • Other terms related to epiphyseal growth

    • atavistic e.: a bone that fuses naturally to another bone as in the coracoid process of the scapula.

    • primary center of ossification: the first site where bone begins to form in the shaft; in a long bone, the diaphysis; also called punctum ossificationis primarium.

    • punctum ossificationis: point of ossification (center) where bone begins to form in a specific bone or part; also called ossification center.

    • secondary center of ossification: a center of bone formation that appears later, on the joint side of a growth plate where the center of ossification is a part of bone that has a strong muscle attachment outside of the diaphysis; also called punctum ossificationis secundarium.

  • sesamoid: a small, round bone found in tendons (and some muscles), whose function is to increase movement in a joint by improving angle of approach of tendon into its insertion. The patella is the largest sesamoid bone in the body.

  • spongiosa: term applied to cancellous or trabecular bone typically in the metaphysis. The term primary spongiosa is applied to the spicular bone in growth plate that forms on the surface of calcified cartilage on the bone side of the physis. Primary spongiosa remodels into trabecular bone.

  • subchondral bone: bone directly under any cartilaginous surface.

  • trabecula: type of bone that is in small interconnected spicules, normally referred to as trabecular bone (cancellous bone) ; predominantly makes up the ends of long bones.

  • trabecular pattern: refers to the arrangement of the trabeculae of bone such that, when seen on radiographs or in cross-sections, there is a pattern of arches or other designs, like the spokes of a bicycle, providing the structural needs of the bone.

  • tubercle (small), tuberosity (large): rounded, elevated projection of bone giving attachment to a muscle or ligament; for example, ischial tuberosity or Lister’s tubercle (dorsal, of radius).

  • Volkmann canals: found in osteonal bone; lateral passageways for transporting nutrients from the central haversian canals to bone cells (osteocytes).

  • woven bone: immature bone seen in very early growth and development, fracture healing, and some disease states. Also called wormian bone and fiber bone.

    • coarse woven bone: rapidly developing woven bone with coarse-appearing matrix; also called burlap bone.

    • fine woven bone: bone with smooth-appearing matrix but that is not lamellar; also called linen bone.

Fig. 8-1Composition of bone. (From Young CG, Barger JD: Learning medical terminology step by step, ed 3, St Louis, 1975, CV Mosby.)

Fig. 8-2Cartilage on surface of soup bone. Dime for contrasts to strip or removed cartilage. Cartilage within bone is the growth plate cartilage.

General Surgery of Bone

  • bone marrow biopsy: surgical or local needle aspiration of bone marrow for microscopic inspection to determine the presence of disease affecting bone, usually drawn from superior iliac crest.

  • bone marrow transplant: a special procedure done in an effort to treat certain disease conditions of bone marrow. Diseased marrow is chemically destroyed and replaced (transfused) with healthy donor marrow of the same blood type. The transfused cells eventually matriculate to recipient’s bone marrow where, in successful transplant, they become established.

  • bone suture fixation: placement of a a peg or screw device to affix, or anchor, a suture to bone for capsular, ligamentous, or tendon repair. There are numerous brands of permanent and absorbable devices.

  • callotasis: for lengthening a bone; production of fracture and then gradual distraction.

  • closed reduction: without incision manual manipulation of the fractured part, with return to proper position (called apposition) and alignment. Also referred to as setting of a fracture or fracture setting .

  • condylectomy: excision of a condyle at the joint; more specifically, removal of the round bony prominence of the articular end of bone.

  • condylotomy: surgical incision or division of a condyle or condyles (e.g., toe phalanges).

  • corticotomy: complete transection of the cortex of a bone without transection of the intramedullary structures. This procedure is basically an osteotomy with care taken to preserve the intramedullary vessels.

  • diaphysectomy: removal of the shaft of bone, leaving the distal and proximal ends of bone intact.

  • diaplasis: reduction of a fracture or dislocation.

  • distraction osteogenesis: lengthening of bone by gradually pulling apart and allowing bone to grow into the created gap.

  • ebonation: removal of fragments of bone from a wound.

  • epiphysiodesis: fusion of an epiphysis to the metaphysis of a bone by disruption of the growth plate (epiphysiolysis) or by metallic fixation between the epiphysis and metaphysis of bone. An epiphysiolysis may also occur traumatically.

  • fenestration: cutting a window in bone to allow drainage or access to an object covered by the bone, such as a tumor or foreign body.

  • open reduction: surgical incision and correction of a bone alignment of a fracture; may or may not include stabilization with internal or external fixation.

  • ostectomy: removal of a portion of bone.

  • osteoarthrotomy: the excision of the articular end of bone.

  • osteoclasis: surgical fracture or refracture of bone to bring about a change in alignment in cases of nonunion or malalignment.

  • osteoplasty: surgical correction by shaping or formation of bone (osteorrhaphy).

  • osteosynthesis: surgical fixation and stabilization of bone.

  • periosteotomy: incision through the membranous covering of bone; also called periostomy.

  • sequestrectomy: removal of a portion of dead bone.

  • synostosis: surgical fusion of any two or more bones that would otherwise be separated; may occur in a natural state as well.


An osteotomy is a cutting or incision of bone, usually to produce a change in bone shape or alignment. It may be considered for correction of a malaligned fracture, osteoarthritis, or other joint conditions. The following procedures are types of osteotomies.

  • Abbott and Gill o.: for bone growth asymmetry in lower limbs; a distal femoral and proximal tibial epiphysiodesis done through a medial approach. Also, proximal tibial and fibular epiphysiodesis through a lateral approach.

  • Amspacher and Messenbaugh o.: for cubitus varus with rotatory deformity of the elbow; correction of both deformities is with a distal humeral osteotomy.

  • Amstutz and Wilson o.: for congenital coxa vara.

  • Bailey and Dubow o.: for deformities of the femoral shaft; multiple osteotomies held by a telescoping intramedullary rod.

  • Baker and Hill o.: for heel valgus; lateral opening wedge osteotomy with bone allograft.

  • ball-and-socket o.: dome-shaped osteotomy.

  • Bellemore and Barrett o.: for varus deformity of elbow; lateral closing wedge osteotomy of distal humerus; also called modified French o.

  • Bernese o.: for acetabular dysplasia, osteotomy of pubis and ischial-ilial part of acetabulum that allows for more anatomic rotation of entire acetabulum, held in place by internal fixation. Also called Ganz o. and periacetabular o. (PAO).

  • Blackburn o.: use of multiple drill holes to create a controlled fracture.

  • Blount o.: for bone growth asymmetry in the lower limbs; epiphyseal growth is arrested using staples across the growth plate.

  • Blount displacement o.: for hip osteoarthritis.

  • Blundell Jones varus o.: varus osteotomy of the hip for paralysis.

  • Borden and Gearen o.: for aseptic necrosis of the hip; an extracapsular transtrochanteric osteotomy.

  • Borden o.: for coxa vara; see also Spencer o. and Herndon o.

  • Brackett o.: ball-and-socket type for the fused hip.

  • Brett o.: for proximal tibia for genu recurvatum.

  • closing wedge o.: wedge cut out of bone; the closing of the open space angulates the bone toward the side from which the wedge was removed.

  • Chiari o.: for slipped capital femoral epiphysis; a subcapital osteotomy. For acetabular dysplasia; a shelf type osteotomy.

  • Cole o.: anterior tarsal wedge for cavus deformity.

  • Cotton o.: for correction of a distal tibial deformity.

  • Coventry o.: a proximal tibial osteotomy for varus or valgus knees.

  • Crego o.: for femoral anteversion.

  • cuneiform o.: a cuneiform-shaped wedge cut in bone allowing for correction of deformities in two planes.

  • derotation o.: correction of rotational misalignment of a long bone.

  • dial o.: dome- or circular-shaped osteotomy. Also called barrel vault o.

  • Dickson o.: for malunion of the femoral neck.

  • Dimon o.: for intertrochanteric fractures; medial displacement of the distal fragment; also called Hughston o.

  • Dwyer o.: for clubfoot and pes cavus deformities; a lateral closing wedge osteotomy that reduces both the cavus and heel varus deformities.

  • Ferguson-Thompson-King-Moore o.: for long-bone deformity such as malunion; a concave side resection of cortex with replacement after bone is made into chips, careful closure of the periosteum over the chips, and then closing wedge osteotomy on opposite side after sufficient callus formation has taken place.

  • Fish o.: for fixed slipped capital femoral epiphysis deformity; a cuneiform osteotomy at the base of the femoral head.

  • French o.: for cubitus varus (elbow); a closing wedge osteotomy.

  • Gant o.: open-wedge osteotomy for the fused hip.

  • Ganz o.: for adult acetabular dysplasia; a periacetabular osteotomy.

  • Ghormley o.: part of a hip fusion procedure.

  • Hass o.: for dislocation of the hip.

  • Hefney o.: for tibia vara; an epiphyseal osteotomy avoiding physis.

  • Hernigou o.: for severe tibia vara; a medial opening wedge osteotomy.

  • Ingram o.: for fusion of growth plate because of trauma; opening wedge osteotomy with concurrent insertion of fat at growth plate area.

  • innominate o.: of the pelvis for dislocation of the hip; two common types are Pemberton o. and Salter o.

  • Irwin o.: for genu recurvatum; a posterior closing wedge osteotomy of the proximal tibia.

  • Kramer, Craig, and Noel o.: for fixed slipped capital femoral epiphysis deformity; osteotomy at base of femoral neck.

  • Langenskiöld o.: to correct partial premature closure of growth plate; an excision of bony bridge across the epiphysis with insertion of fat.

  • Lorenz o.: for dislocation of the hip.

  • Lucas and Cottrell o.: notched rotation type of the proximal tibia.

  • Macewen and Shands o.: for congenital coxa vara.

  • Martin o.: for fixed slipped capital femoral epiphysis deformity; a closing wedge osteotomy at the base of femoral head and superior neck.

  • McKay o.: for stabilization of the hip in myelomeningocele; varus osteotomy of the proximal femur with transfer of adductors to the ischial tuberosity and external oblique muscles to the greater trochanter.

  • McMurray o.: for nonunion of the femoral neck.

  • Meyer-Burgdorff o.: for recurrent anterior dislocation of the shoulder; a proximal humeral osteotomy.

  • Moore o.: for long-bone deformity such as a malunion; a three-quarter-width wedge resection with replacement after bone is made into chips, careful closure of the periosteum over the chips, and then closed manipulation after sufficient callus formation.

  • Müller o.: for osteoarthritis of the hip; an intertrochanteric varus osteotomy.

  • open-wedge o.: straight cut made across the bone, creating angulation, and leaving an open wedge-shaped gap.

  • Osgood o.: for correction of malrotation of the femur.

  • Paulos o.: derotational high tibial osteotomy.

  • Pauwels o.: for nonunion fracture of the femoral neck.

  • Pauwels-Y o.: for congenital coxa vara.

  • Phemister o.: for bone growth asymmetry in the lower limbs; a block of bone is fashioned at the growth plate and then rotated 90 degrees.

  • Phillips p.: anterior cruciate ligament and anterolateral ligament reconstruction in athletes; medial patellofemoral ligament reconstruction; transtibial pullout repair of radial or meniscal root tear.

  • Platou o.: for femoral anteversion.

  • Pott eversion o.: for correction of a distal tibial deformity.

  • Rab o.: for Blount disease; a two plane proximal tibial osteotomy.

  • redirection o.: term typically applied to acetabular osteotomy in which the acetabulum is redirected to give more appropriate orientation for the femoral head in cases of dysplasia and in some Legg-Calvé-Perthes disease. Also called periacetabular osteotomy (PAO), Bernese o., Ganz o., triple o., Steele o., and Wagner o.

  • San Diego p.: for pediatric hip dysplasia; modification of Pemberton osteotomy.

  • Sanders o.: for tibia malunion, and oblique osteotomy.

  • Sarmiento o.: for intertrochanteric fractures; a wedge-shaped piece of bone is resected from the distal fragment to achieve a valgus osteotomy.

  • Sofield o.: multiple osteotomies of the tibia or femur for bowing deformities caused by osteogenesis imperfecta or nonunions.

  • Southwick o.: for slipped capital femoral epiphysis; a combination lateral and anterior trochanteric closing wedge osteotomy.

  • Speed o.: for malunion of the distal radius.

  • spike o.: creation of a bony spike in a long bone to help hold the fixation of position.

  • Steel o.: for acetabular dysplasia; a triple innominate osteotomy.

  • Stricker o.: for Legg-Calvé-Perthes disease; a varus derotational osteotomy.

  • Sugiuka o.: for avascular necrosis of femoral head; the femoral head and neck are rotated to transpose the avascular area away from the weight-bearing portion of the joint.

  • Thompson telescoping V o.: used in distal femoral deformities.

  • Weber o.: internal rotation osteotomy of the proximal humerus for recurrent dislocation associated with large posterior humeral head defect.

  • Whitman o.: closing wedge procedure for the fused hip.

  • Y o.: for cavus deformity of the foot; also called Japas o.

Bone Grafts

Bone grafts are used several hundred thousand times annually in the United States to aid in repair or reconstruction of the skeleton. The scope of applications is associated with congenital (skeletal hypoplasia, pseudarthrosis), developmental (scoliosis), traumatic (fractures, segmental loss), degenerative (osteoarthritis), and neoplastic (benign, malignant) disorders. Bone grafts can be autogenous or allogenic. Advantage of autologous bone graft include maximal biologic potential, histocompatibility, and no potential of transfer of disease from donor to recipient, while allogenic bone grafting avoids donor site morbidity.

In general, autologous bone grafts are removed from one site and transferred to another without direct reestablishment of the blood supply. Consequently, osteogenic cells fail to survive unless they receive sufficient nutrition by diffusion, a circumstance met only by those cells very close to the bone surface. These few surviving cells play an important role in initiation or augmentation of the early phase of bone graft incorporation.

Bone graft repair depends on local factors at and emanating from the recipient site, including ingrowth of new blood vessels and both specialized and multipotential cells required for resorption and new bone formation. The exception to dependence on local tissues occurs with immediate reanastomosis of the blood supply to the graft, often requiring microvascular techniques.

Today, tissue banks have become research centers for bone marrow, stem cell, and growth factor studies. Because all types of blood cells are produced in the bone marrow, research experiments are limitless. Bone marrow collection (harvesting) is still an important part of tissue banking, as is storage and type-matching of bone, tissue, and blood products, but greater emphasis is now being placed on biomedical research of tissue and bone marrow, and evidence of infectious agents.

General Terminology

  • histocompatibility: immunologic similarity or identity with respect to cell surface antigens determined by genes of the major histocompatibility complex. There are varying degrees of histocompatibility, some consistent with successful transplantation and some incompatible with this approach unless accomplished with immunosuppression.

  • immunosuppression: a term applied to any effort directed at lowering the body’s natural immune response to foreign substances. In transplant physiology, this is the use of specific chemicals and medications to decrease the body’s reaction to transplanted tissues. Nonspecific immunosuppression reduces host responses to most or all antigens and is usually caused by a systemic drug or chemical agent.

  • implant: a synthetic device or the act of transferring into a host a synthetic device. Some include implants to reflect biologic material without cell viability.

  • major histocompatibility complex: a sequence of genes that control expression of cell surface glycoproteins that are recognized as foreign when transferred into a genetically dissimilar host. Different terms are used to identify this gene complex, depending on the species, for example, human leukocyte antigen, histocompatibility-2 in mice, and rabbit leukocyte antigen.

  • transplant: a tissue or organ transferred from one site to another or the act of accomplishing this transfer. Some use this term to denote the transfer of viable tissue only (versus implant), and others use it to refer to any biologic material.

Classification by Source

  • allograft: a tissue or organ transferred between nonidentical members of the same species. Also called allogenic; formerly called homograft.

  • autograft: a tissue or organ removed from one site and placed in another within the same individual; also called autogenous.

  • isograft: a tissue or organ transplanted between genetically identical members of the same species. Synonymous with syngraft (syngeneic); also called isogenic.

  • xenograft: a tissue or organ transferred between species, for example, cow to human, rat to dog. Also called xenogeneic; formerly called heterograft.

Special Procedures for Preserving Bone Grafts

Most grafts are subject to some form of long-term preservation. The most common storage approaches include deep-freezing, freeze-drying (lyophilization), chemosterilization, and chemical extraction of proteins, or combinations of these techniques. These processing procedures may vary from one tissue bank to another. The methods applied to long-term preservation have some effect on biologic, immunologic, and biomechanical properties of the tissue, but these changes are predictable and often compatible with clinical success. Storage permits time for careful assessment of the donor graft material for potentially harmful transmissible diseases. Graft material should be obtained from tissue banks that use strict processing procedures for allograft processing and donor procurement, under the guidelines of the American Association of Tissue Banks.

Bone Recovery Methods

  • autolyzed, antigen-extracted allogeneic (AAA) bone: a chemosterilized, autolyzed antigen-extracted, and partially demineralized allogeneic preparation.

  • chemosterilized grafts: graft material rendered free of microbial organisms by exposure to a chemical, such as ethylene oxide, although thimerosal and alcohol have been used for bacteriostatic properties.

  • demineralized bone graft: one that has undergone extraction of minerals (superficially or completely) usually by exposure to hydrochloric acid.

  • freeze-dried grafts: the removal of water from tissue in a frozen state, the same as lyophilized. With respect to bone, usually reflects residual moisture being reduced to approximately 3% or less by weight. Tissues can be stored indefinitely at room temperature in evacuated, sealed containers until required for use. Moisture is then reconstituted by submerging the tissue in water (saline). Also called lyophilized grafts.

  • fresh-frozen grafts: pieces of bone or cartilage that have been frozen without removal of water or cells in an effort to preserve cells.

  • irradiation-sterilized grafts: exposure of tissues to high-dose ionizing irradiation for the purpose of killing potential pathogens, requiring a dose between 1.5 and 5 megarad.

  • lyophilized grafts: also called freeze-dried grafts.

  • Masquelet technique: for fracture with a large bone defect; initial polymethyl methacrylate spacer for four to six weeks followed by bone grafting with allograft of other substitute.

  • osteoconductive grafts: graft material that allows for bone ingrowth but does not induce bone growth. This can be applied to some demineralized bone matrix materials as well as synthetics.

  • osteoinductive grafts: graft capable of stimulating osteoblast formation.

Revascularization of Grafts

The application of immediately revascularized autografts is limited by expendability of bone at the donor site, a discrete blood supply to the graft, vessels of sufficient caliber for repair (the fibula, ribs, and iliac crest represent the practical limitations), and microvascular expertise. This approach is especially well-suited for recipient sites compromised by prior irradiation or infection or when rapid repair is mandatory.

The incorporation of devitalized grafts occurs by a lengthy process analogous to creeping substitution, in which the sequence of events includes revascularization of the bone, followed by resorption and new bone formation. Autografts transferred on a vascular pedicle or in which the blood flow is reestablished immediately by vascular anastomoses are incorporated rapidly by a process analogous to fracture repair.

In cases of bone allografts, immediate reanastomosis of blood supply is not clinically feasible because it engenders the same immunologic considerations encountered with viable solid organ transplantations, adding the requirement for substantial immunosuppression of the recipient. The following are related terms.

  • creeping substitution: the process by which a devascularized segment of bone in situ or a transferred bone without immediate reanastomosis of its blood supply undergoes repair, beginning with vascular invasion, followed by bone resorption and subsequent new bone formation (incorporation). This is a lengthy process that may take large cortical segments several years to incorporate, and even then, substantial portions of the graft may escape remodeling.

  • free-revascularized autograft: tissue transferred to a distant site along with its discrete blood supply such that direct reanastomosis of circulation can be accomplished immediately.

  • incorporation: a process by which recipient site factors grow into and remodel an initially devascularized bone graft. This includes invasion by blood vessels, resorption, and new bone formation. Often used interchangeably with creeping substitution with reference to grafts.

Classification of Grafts by Bone Type

  • cancellous g.: a bone transplant consisting of cancellous (or medullary) tissue as opposed to cortical bone.

  • composite g.: a transfer of more than one type of tissue simultaneously, such as bone and muscle transferred at the same time, or bone, muscle, and skin transferred simultaneously; must be accomplished in conjunction with reanastomosis of blood supply at the recipient site. This provides the potential advantage of repairing both bone and soft tissue defects simultaneously.

  • cortical g.: a transferred bone composed of the cortical (outer) tissue.

  • strut g.: cortical bone graft used to give mechanical support in the area of a cancellous bone graft.

  • corticocancellous g.: transferred bony tissue with both cortical and cancellous elements.

  • free g.: a bone graft freed of its vascular supply and soft tissue that would encumber its transfer from one location to another. This includes free revascularized autografts as well as other bone graft preparations.

  • intercalary g.: a segment of transferred bone without an articular surface; usually a portion of diaphysis or diaphysis plus metaphysis, with bone intercalated into bone to reestablish continuity.

  • intramedullary g.: graft placed in medullary canal. Also called medullary graft.

  • osteoarticular g.: bone graft containing an articular surface.

  • osteochondral g.: a transplant composed of both bone and cartilage (articular surface).

  • osteoperiosteal g.: bone graft taken complete with periosteal membrane coverings.

  • pedicle g.: tissue transferred to another site while retaining (at least temporarily) its required blood supply at the donor site, consequently limiting the distance over which a pedicle can be transferred. The recipient site vascularity can be transected or interrupted following reestablishment of sufficient vascularity at the recipient site.

  • segmental g.: a portion of transferred tissue representing less than the entire anatomic part being replaced.

Classification by Shape and Bone Grafted

  • bone block: a bone graft that is inserted next to a joint to prevent a given direction of motion in that joint; also, a bone graft that is shaped in the form of a block and used for fusion of a joint.

  • chip g.: bone graft broken up into chips.

  • clothespin g.: coarsely shaped graft used in the spine; resembles a clothespin.

  • hemicylindric g.: graft cut into the shape of half a cylinder.

  • inlay g.: any graft that has been cut in a fusion procedure to fit the shape of the graft site.

    • diamond inlay g.: graft cut in a diamond shape with recipient site cut to receive that shape.

    • sliding inlay g.: a slot of bone cut and moved across the graft site, usually a fracture of a large bone.

  • massive sliding g.: large graft designed to slide when two portions of recipient bone are compressed.

  • morcellized g.: cortical or cancellous bone graft that has been finely crushed before implanting.

  • onlay g.: graft laid directly onto the surface of recipient bone.

    • dual onlay g.: two strips of bone laid down on either side of the shaft.

  • peg g.: cylindric bone graft to be inserted into or through the medullary canal of a bone.

    Eponymic Bone Graft Terms

    Albee Hey-Grooves-Kirk
    Banks Hoaglund
    Boyd Huntington
    Campbell Inclan
    Codivilla McMaster
    Flanagan and Burem Nicoli
    Gillies Phemister
    Haldeman Ryerson
    Henderson Soto-Hall
    Henry Wilson

Osteosyntheses: Internal Fixation Devices for Fracture Healing

Osteosynthesis is a surgical procedure that uses internal fixation devices, especially in the treatment of fractures. This procedure is referred to in context as open reduction and internal fixation (ORIF). It cannot be overemphasized how the orthopaedic surgeon must apply the principles of engineering to biology. The surgeon must be adept in using metal plates, nails, rods, pins, bands, screws, bolts, and staples in the correction of skeletal defects ( Fig. 8-3 ). Pegging, pistoning, reefing, shelving, shaving down, shucking, doweling, and saucerization are a few of the shaping and engineering procedures applied within biologic principles. The following internal fixation devices are used or have been used in the past in orthopaedic surgery.

  • antegrade nail: any nail or rod inserted from proximal to distal in the medullary canal of a bone.

  • AO: abbreviation for an international organization dedicated to the study of fractures and their proper treatment. The letters stand for Arbeitsge-meinschaft für Osteosynthesefragen.

  • ASIF: abbreviation for group that studies internal fixation systems and engineering. The letters stand for Association for the Study of Internal Fixation.

  • Asnis screw: for hip cervical fractures; a cannulated screw with reverse cutting thread. (No longer used.)

  • Badgley nail: for hip fractures; an uncannulated triflanged nail with beveled proximal end that can be attached and inserted through a special side plate.

  • Bailey-Dubow nail: for osteogenesis imperfecta; an extensible intramedullary nail used in osteotomies.

  • Basile screw: for hip cervical fractures; a drill point tip screw with pronged washer to be placed over trochanter for compression. (No longer used.)

  • Benoit-Gerrard: for hip fractures; a spring-loaded sliding nail plate with a proximal outside thread, smooth shaft, and a side plate; provides continuous compression. (No longer used.)

  • biodegradable fixation: a variety of screws, pins, plates, and other fixation devices made of material that will be absorbed by the body. Such materials include plastic made from single or combined glycolic acid, lactic acid, and other small organic acids capable of forming two polymers.

  • blade plate: general class of implant in which the plate is precontoured into a fixed angle, most commonly 95 degrees.

  • Blount plate: for fixation of hip fractures and for reconstructive procedures about the hip; a blade plate that can be bent easily to adjust to the correct shape and angle. (No longer used.)

  • Blount staple: type of staple used around the knee.

  • Bohler nail: for hip fractures; a triflanged nail with potential use of a side plate. (No longer used.)

  • Bohlman pin: for hip fractures; a threaded pin with a sharp point and smooth proximal portion. (No longer used.)

  • bollard: a short, flat-headed, nail-like device that is slotted along a portion of the shaft, used in fixation of ligaments into bone. (No longer used.)

  • Boyd side plate: to help stabilize trochanteric portion of hip fracture; a plate that could be placed over plate of a Jewett nail. (No longer used.)

  • Brooker-Willis nail: for unstable femoral fractures; a femoral nail with distal locking screws. (No longer used.)

  • buttress plate: T or other shaped plate to support distal end fractures.

  • cable: threaded wire that can be tightened circumferentially around a piece of bone.

  • Calandruccio device: a metallic device for pantalar fusions. (No longer used.)

  • Calandruccio nail: for hip fractures; a sliding compression screw and plate associated with two to four smaller threaded pins through the plate and into the femoral head for extra fixation. (No longer used.)

  • cancellous screw: used for trabecular problems near the joints, especially the hip.

  • cannulated nail or screw: general terms used for nails and screws that have a hole in the center. This hole can be used to direct the nail or screw over a guide wire.

  • Caspari p.: for lateral tibial plateau fracture; arthroscopically-assisted fracture reduction and percutaneous fixation.

  • cephalomedullary interlocking nails: for combination femoral shaft and femoral neck fractures.

  • cerclage wire: for fracture fixation; any wire that circles the shaft of a bone or fracture fragment.

  • Chapman and Henley p.: for complex long bone fractures; double plate fixation.

  • Charnley screw: for intracapsular hip fractures and hip arthrodesis; a compression screw that slides into a barrel and attaches to a side plate. (No longer used.)

  • Cho p.: for osteogenesis imperfecta; use of expandable modified rod with interlocking obturator.

  • cloverleaf nail: used in femoral shaft fractures. (No longer used.)

  • cobra plate: plate that is shaped like the head of a cobra at the end of a plate used to hold the femur to the pelvis in hip fusion surgery.

  • compression staple: metallic U shaped device designed to produce linear compression between fracture or osteotomy fragments

  • cortical screw: used in dense lamellar (cortical) bone. Has smaller thread diameter to diminish chance of cracking hard bone compared with cancellous screws. Similar to machine screws.

  • Crawford-Adams pin: for hip fracture; use of small threaded pins. (No longer used.)

  • cruciate screw: screw with cross-shaped head.

  • Dall-Miles cable: a grip device for reattachment of a trochanteric osteotomy.

  • Delta nail: for femoral shaft fractures; a nearly triangular nail with interlocking screws. (No longer used.)

  • Derby nail: for femoral shaft fracture; an intramedullary nail with wings that can be extended at the distal tip, and an antirotation washer at the proximal end. (No longer used.)

  • Deyerle pin: for intracapsular hip fracture; thick, wide plate with multiple holes to permit the insertion of numerous pins parallel to one another. (No longer used.)

  • dome plunger: device to facilitate injection of cement into femoral head for better fixation of sliding device.

  • Dooley nail: for intracapsular hip fractures; a modified Smith-Petersen nail that has an external groove around the base. (No longer used.)

  • dynamic-compression plate (DCP): plate fixation designed to allow compression between fracture fragments with the proper order of screw insertion.

  • dynamic hip screw (DHS): for intertrochanteric hip fractures; designed to allow compression between fracture fragments with normal forces of weight bearing.

  • Eggers plate and screw: used in long-bone fractures. (No longer used.)

  • elastic stable intramedullary nailing (ESIN): for fixation of femoral fractures in children; insertion of a highly elastic intramedullary nail that allows early protected weight-bearing.

  • Elliott plate: a type of blade plate used mostly in distal femoral procedures. (No longer used.)

  • encerclage: wiring or banding of bony fragments in the shaft of a bone or for onlay grafts.

  • Ender nail: intramedullary nail that is curved and can be used to fix intertrochanteric hip fractures through a small incision just above the knee joint; used in a condylocephalic technique.

  • exchange nailing: use of a larger nail after failure of fixation or union with a smaller nail.

  • Fassier-Duval telescoping rod: for leg length discrepancy in osteogenesis imperfecta.

  • Gaenslen spikes: for intracapsular hip fractures; smooth spikes driven from a small incision of greater trochanter. (No longer used.)

  • Gamma nail: for hip fractures; a screw and nail device.

  • Garden screws: for intracapsular hip fracture; large cannulated screws usually used in pairs and inserted at varus and valgus angles. (No longer used.)

  • Giebel blade plate: blade plate with two screws for fixation of proximal tibial osteotomy. (No longer used.)

  • Godoy-Moreira stud-bolt: for intracapsular hip fracture; an early model compression screw with external flange and bolt. (No longer used.)

  • Gore AO screw: AO cortical bone screw modified to affix a ligament replacement implant. (No longer used.)

  • Gouffon pin: pointed, threaded pin used in the fixation of cervical neck fractures of the hip. (No longer used.)

  • grommet: a short, flat, hollow cylinder with a head. The device fits over a screw that is considerably narrower than the inner portion of the grommet. Used for fixation of ligaments into bone.

  • Gross-Kemph nail: for unstable femoral shaft fractures; an interlocking nail system. (No longer used.)

  • Green-Seligson-Henry (GSH) nail: for supracondylar fractures; nail inserted through intercondylar notch. (No longer used.)

  • GSU nail: for distal intraarticular fracture of femur; a retrograde nail inserted through joint with nail fixed by transcortical screw. (No longer used.)

  • Haboush universal nail: for intracapsular hip fractures; a fenestrated plate with a shallow H cross-section; inserted into head and neck of femur, and outside portion bent down over lateral side of femur. (No longer used.)

  • Hagie pin: used for femoral neck fractures. (No longer used.)

  • Hansen pin: for intracapsular hip fractures; use of nonthreaded, wide pins. (No longer used.)

  • Hansen-Street nail: used for larger bone fractures. (No longer used.)

  • Hardinge expansion bolt: for intracapsular hip fractures; a hollow screw with expandable tip and short side plate for femur. (No longer used.)

  • Harrington rod: used in spinal fixation for scoliosis and some fractures.

  • Harris four wire fixation: for repair of a trochanteric osteotomy.

  • Harris nail: intramedullary nail system for intertrochanteric fractures. (No longer used.)

  • headless compression screw : screw designed with variable pitch threads to allow for compression while keeping the screw below the surface of the bone; mostly used for fixing fractures of articular cartilage.

  • Henderson lag screw: used for hip fractures. (No longer used.)

  • Herbert screw: for wrist scaphoid fixation; a short screw threaded at both ends; also used in fixation of other small bone fractures or osteotomies such as bunion surgery.

  • Hessel-Nystrom pin: threaded pin for internal fixation of femoral neck fractures. (No longer used.)

  • hex screw: hexagon head screw.

  • Higley side plate: for hip fractures; a side plate that could be attached superiorly for screw fixation into greater trochanter. (No longer used.)

  • Holt nail: for hip fractures; a one-piece nail-plate combination, with plate fixed by Barr nuts and bolts. (No longer used.)

  • hook-pin fixation: for femoral neck fractures; a hollow nail has internal hooked pins that can be deployed into the femoral head after introduction of the nail.

  • Howmedica compression screw: for hip fractures; wide compression screw with side plate and hexagonal shape to cross-section of shaft and barrel to prevent rotation. (No longer used.)

  • Hubbard side plate: for hip fractures; a wide, long femoral side plate designed to be used with triflanged nail. (No longer used.)

  • Huckstep nail: for osteotomy of femur with limb lengthening; a nail with holes for cross-screw fixation. (No longer used.)

  • interlocking nails: class of rod fixation devices that have transfixing screws to prevent rotation.

  • InterTan (InterTAN) nail: used for intertrochanteric femoral fractures.

  • intramedullary nail: class of nails placed in medullary canal of long bones for fracture stabilization; includes Hansen-Street, Küntscher, Lottes, and Schneider.

  • Inyo nail: for fractures of the distal fibula, a tapered V-shaped nail made of malleable stainless steel. (No longer used.)

  • Jewett nail: nail plate used in hip fractures. (No longer used.)

  • Johansson nail: for hip fractures; a triflanged nail that is cannulated and similar to a Smith-Petersen nail. (No longer used.)

  • Ken nail: 135-degree sliding nail plate used for hip fractures. (No longer used.)

  • Kirschner wire (K-wire): small wire used for fixation or traction.

  • Klemm nail: for femoral shaft fractures; a cloverleaf intramedullary nail with provision for proximal and distal screws. (No longer used.)

  • Knowles pin: used for hip fractures. (No longer used.)

  • Küntscher nail: original form was a cloverleaf-shaped nail for simple shaft fractures of the femur. Subsequent modifications are a curved V-shaped nail for valgus reductions of intracapsular hip fractures; a self-locking Y device for hip fractures in which the hip nail has an open base for the passage of a cloverleaf intramedullary nail; and a device for unstable shaft fractures with interlocking proximal and distal screws. Also called Küntscher rod. (No longer used.)

  • Kurosaka screw: special screw designed for fixation of tendon attached to bone in ligament reconstruction.

  • lag screw: a screw inserted to produce interfragmentary compression across a fracture; can be by design (partially threaded screw) or by technique.

  • Laing H-beam nail: for hip fractures; an H-shaped nail with an adjustable side angle plate. (No longer used.)

  • Lane plate: plate for long-bone fixation. (No longer used.)

  • Leinbach screw: long, flexible screw; used often for olecranon fractures. (No longer used.)

  • less invasive stabilization system (LISS) plate: a method for plating long bone fractures in which the plates and screws are inserted in a submuscular technique to avoid excessive stripping of muscles and periosteum; can utilize a combination of locking and non locking screws.

  • Lewis nail: intramedullary nail for metacarpal bone fixation.

  • limited-contact dynamic-compression plate (LC/DCP): plate for fixation of long-bone fractures and osteotomies in which there is only focal point of contact of the plate to minimize the amount of periosteum necrosis beneath the plate. Plate insertion is designed to produce compression between fracture fragments with proper screw insertion.

  • Lippman screw: for hip fractures; a threaded compression screw with a smooth shaft and threaded base with washer. (No longer used.)

  • locked intramedullary osteosynthesis (LIFO): for unstable long-bone fractures; a set of flexible 4- or 5-mm diameter pins with a device for proximal interlocking and fixation of two of the pins.

  • locking plates: plates where the screw heads “lock” into the plate through threaded heads of the screws that correspond to threaded holes in the plates; designed to maximize screw purchase and strength in osteoporotic bone or to stabilize fractures in regions of the metaphysis or epiphysis.

  • Lorenzo screw: bone fixation screw. (No longer used.)

  • Lottes nail: used for tibial fractures. (No longer used.)

  • Luck nail: several different designs for hip fractures; triflanged nail in which the distal end has multiple perforations to cut off excess length, a proximal pointed nail that can accept a side plate, and a V-shaped nail-plate combination. (No longer used.)

  • Lundholm screw: for hip fractures; compression screw with proximal washer and nut that could be used with or without side plate. (No longer used.)

  • Mancini plate: for hip fractures; side plate with multiple-angled screw holes. (No longer used.)

  • Martin screw: used in hip fractures. (No longer used.)

  • Massie nail: 155-degree sliding nail used in hip fracture. (No longer used.)

  • McLaughlin plate or screw: used in hip surgery. (No longer used.)

  • Medoff sliding plate: for fixation of intertrochanteric and subtrochanteric femur fractures; plate is slotted to allow central portion to slide distally. (No longer used.)

  • medullary rod: metallic device used in central shaft of bone.

  • minimally invasive plate osteosynthesis (MIPO): concept of applying plate and screws to fix fractures with small incisions and limited damage to the soft tissue attachments. See also less invasive stabilization system (LISS) plate.

  • Moe plate: for hip fractures; a long lateral plate over femoral shaft and greater trochanter fixed with multiple screws. (No longer used.)

  • Moore plate or pin: used in hip surgery. (No longer used.)

  • Morscher plate (AO-Morscher plate): for anterior cervical fusion. (No longer used.)

  • Müller plate: type of blade plate used in hip surgery. (No longer used.)

  • Murphy nails: for early attempts at fixation of hip fractures; 8 to 12 penny nails inserted across fracture site. (No longer used.)

  • Nancy nail: elastic stable intramedullary nails used for pediatric long-bone fractures.

  • nested nails: a general term for two nails placed side by side in the medullary canal of long bones.

  • Neufeld nail: for hip fractures in older adults; a V-shaped proximal end portion with short side plate. (No longer used.)

  • Neufeld pin: for hip fractures; smooth rods with notches easily broken off to adjust length. (No longer used.)

  • Ogden plate: for fixation of long-bone fractures associated with preexisting intramedullary devices such as rods or the stem of a prosthesis. Long metal plates have slots that are designed to accept encircling bands in locations where screws cannot be easily used. (No longer used.)

  • olive wire: to help approximate a bone fragment in external skeletal fixation; a small, olive-shaped expansion on a fixation wire can be pulled through the skin to the surface of the small fragment and brought against the main portion of bone.

  • Parham band: for oblique long-bone fractures; a metal band that can be tightened around the shaft of the bone to achieve fixation by compression. (No longer used.)

  • Partridge band: for oblique long-bone fracture; a band with ribbed undersurface so that when band is tightened there might be less interference with periosteal and cortical blood flow. (No longer used.)

  • PGP nail: a flexible nail used in intramedullary fixation of femoral fractures. (No longer used.)

  • Phillips screw: any screw with a Phillips head.

  • Pidcock pin: for hip fractures; a small pin that could be passed through a hip nail and into the lateral cortex to prevent shortening. (No longer used.)

  • Preston screw: for hip fractures; original screw and side plate device. (No longer used.)

  • Puddu plate: system for fixation of osteotomies that uses a block built into the plate to maintain an opening wedge.

  • Pugh nail: 155-degree sliding nail used for hip fractures. (No longer used.)

  • Putti screw: for hip fractures; a compression screw that can be attached to a flange and nut or to a Mancini plate. (No longer used.)

  • retrograde nail: any nail or rod inserted from distal to proximal in the medullary canal of a bone

  • Richards screw: for hip fractures; a sliding compression screw with side plate held by smaller screw to cortex.

  • Rush nail: stiff intramedullary rod with hooked end used for long bone fixation; also called Rush rod and Rod pin.

  • Russell-Taylor nail: intramedullary nail for femur with slots for cross-screw fixation.

  • Rydell nails: for femoral neck fractures; a four-flanged spring-nail. (No longer used.)

  • Sage rod: diamond-shaped rod used in forearm fractures. (No longer used.)

  • Sarmiento nail: for hip fractures, an I-beam with side plate. (No longer used.)

  • Schanz pins: for external skeletal fixators; screw fixation pins with proximal smooth surface for attachment to the fixation device.

  • Schneider nail or rod: used in femoral shaft fractures.

  • Seidel nail: for humeral fractures; a proximal and distal interlocking nail. (No longer used.)

  • Sheffield rod: for osteogenesis imperfecta; an extensible intramedullary nail used for osteotomies.

  • Sherman plate: used for long-bone fractures. (No longer used.)

  • side plate: used the plate portion of an angular screw or blade construct.

  • Smillie nail: small pin used for attachment of the osteochondral fragments in the knee. (No longer used.)

  • Smith-Petersen nail: flanged nail used in hip surgery. (No longer used.)

  • Smyth pin: for hip fracture; attachment of two different sized, nonparallel screws through a plate over the greater trochanter. (No longer used.)

  • Steinmann pin: used in skeletal traction; of larger caliber than a K-wire.

  • Street medullary pin: used for large long-bone fractures. (No longer used.)

  • Street nail: split diamond nail for hip fixation. (No longer used.)

  • Thompson nail: for nondisplaced intracapsular hip fractures; a Z-shaped nail. (No longer used.)

  • Thornton nail: for femoral neck fractures; a three-flanged spring-nail. (No longer used.)

  • tibial bolt: used for proximal and distal tibial fractures.

  • Tieman-Jewett nail: for hip fracture; a one-piece triflanged nail and side plate. (No longer used.)

  • tightrope: a suture device used to produce dynamic compression and stability across ligamentously disrupted joints such as the ankle syndesmosis.

  • toggle: a small metallic cylinder with each end slightly larger than the center. Used by tying sutures around it to affix ligaments or tendons to bone.

  • Tronzo nail: triflanged nail used alone or with side plate. (No longer used.)

  • True-Flex nail: for fixation of long-bone fractures; fluted intramedullary rods. (No longer used.)

  • Uppsala screw: for intracapsular hip fracture; multiple, wide, threaded screws. (No longer used.)

  • variable angle locking screws: locking screws capable of insertion through a broader range of angles, usually through a pre established insertion cone.

  • Venable screw: original Vitallium screw. (No longer used.)

  • Veseley-Street nail: for femoral shaft fractures; a splitting of a diamond nail both distally and proximally. (No longer used.)

  • Virgin screw: for hip fractures; a compression screw using a proximal washer and spring. (No longer used.)

  • von Bahr screw: for femoral neck fracture; a pin threaded at the tip for multiple screw fixation. (No longer used.)

  • Watson Jones nail: for hip fractures; a triflanged nail with a small proximal pin through the nail and into lateral cortex. (No longer used.)

  • Weiss spring: spring device used in some spinal fusions, particularly spondylolisthesis. (No longer used.)

  • Williams nail: for hip fractures; a modified Küntscher cloverleaf Y nail using a locking nut to secure fixation. (No longer used.)

  • Williams rod: for pediatric osteogenesis imperfecta deformity or congenital pseudarthrosis of tibia; rod that is inserted through calcaneus into tibia after osteotomy.

  • Wilson plate: for spinal fusions. (No longer used.)

  • Zickle nail: a curved 75- and 60-degree nail and screw device for femoral supracondylar fracture; or an intramedullary rod with transfixing nail for subtrochanteric fractures. (No longer used.)

  • Zuelzer hook plate: commonly used in ankle fractures. (No longer used.)

Fig. 8-3Two internal fixation devices for hip fractures.

External Skeletal Fixation for Fractures

The use of external wires transfixed through one or both cortices of bone to hold the position of a fracture is not new. Pins in plaster have been used for holding bone fragments in proper position during healing process. There has been increased use of multiple pins placed in or through bone and held together by one or more external devices. These external fixation devices are also known as fixateurs or fixators. This allows easy access to wounds, adjustment during the course of healing, and more functional use of the involved limb. External fixation is a diverse system for managing loss of skeletal stability with various components placed in bone. An external fixator is described procedurally as monoplanar or multiplanar. Fixators applied to an extremity are most commonly a combination of monoplanar devices. Two pins with a clamp or connecting bar between them on any given bone segment compose a monoplanar fixator. Several monoplanar segments can be applied and connected to each other for added stability. An example is a spanning knee frame, in which a monoplanar fixator to the femur and a monoplanar fixator to the tibia are connected to each other. Even though the construct is in more than one unique plane, the application is more that of monoplanar devices. Alternatively, the multiplanar fixator is typically that of the ring or Ilizarov type fixator. The planning and execution of ringed Ilizarov fixators is much more difficult and therefore considered separately.

Other changes to be noticed are the use of modern technologic terms for implants and procedures. Submuscular plating involves placing a plate underneath muscle using peripherally placed cutaneous incisions. Previously, minimally invasive percutaneous plate osteosynthesis (MIPPO) and minimally invasive osteosynthesis (MIO) were terms used to describe the same technique. Locked screws are another new and novel development described frequently. This technology allows for the connection of screw to plate through a threaded or interference interface. One may also hear the term internal fixator, which is a mechanical analogy to that of an external fixator that is “internalized.” Thus a completely locked plate construct placed in a minimally invasive fashion has similar mechanical characteristics to that of an external fixator that is “internalized.” The devices used have increased in number and include the following.

Types by Configuration

  • articulating frame f.: designed to bridge across a joint and allow joint motion.

  • bilateral f.: fixation on both sides of bone, pins cross entire limb.

  • C-clamp f.: occasionally used for emergent treatment of pelvic fractures.

  • circular f.: circular plates that hold thin through-and-through wires under tension to hold fracture or osteotomy fragments; also called ring frame f. and multiplanar frame f.

  • hybrid f.: different techniques are combined such as the combination of a ring system with half-pin fixation.

  • Ilizarov external f.: an evolution of external fixation devices. Also called Ilizarov frame .

  • multiplane f.: fixation on multiple sides or surfaces of a bone, used as an index of complexity in procedural coding.

  • quadrilateral f.: fixation on both sides of bone; pins may or may not cross entire limb; quadrilateral configuration for stability.

  • semicircular f.: curved plates holding thin through-and-through wires under tension to hold fracture or osteotomy fragments.

  • Taylor spatial frame f.: multiplanar external skeletal fixation frame that is capable of correcting deformity using a six-axis computer program to create a virtual hinge and determine sequence of correction.

  • triangular f.: fixation on both sides of bone; pins may or may not cross entire limb; triangular configuration for stability.

  • unilateral f.: fixation on one side of bone; pins do not cross entire limb.

  • uniplane f.: fixation on a single side or surface of a bone; used as an index of complexity in procedural coding.

Physical Stimulation of Fracture Healing

The use of direct electric currents, magnetic impulses, and ultrasound waves in the treatment of fractures has been studied for the effect on fracture healing. In the past, the presence of nonunion (extended failure of fracture healing) has often required extensive surgical attention, including bone grafts. Electric and magnetic stimulation in treating fractures has been approved by the Food and Drug Administration for established nonunion of long bones.

  • capacitive coupling: application of high-­frequency surface electrodes that create smaller currents that stimulate fracture healing.

  • direct electric stimulation: a procedure involving small voltage and amperage electric currents passed through electrodes placed immediately at the fracture site. The source of current is a battery placed external to the body or under the fat, similar to a cardiac pacemaker. For the external battery devices, the electrodes can be placed directly through the skin, eliminating the need for an incision. The limb involved is usually held in a cast.

  • magnetic stimulation: large magnetic coils applied externally and connected to a specific pulsating current. The home treatment device, used to control the magnetic field, is a small, boxlike apparatus that is plugged into a standard 110-volt outlet; can be used up to 12 hours a day. As in electric stimulation, the affected limb is immobilized in a cast during the treatment period. Because pulsed electromagnetic fields are used, the abbreviation PEMF is often used ( Fig. 8-4 ).

    Fig. 8-4Saddle-shaped coil signal generation device. (Courtesy EBI Medical Systems, Inc.)

  • ultrasound stimulation: use of low-intensity sound waves applied externally to increase bone healing.

Internal Prostheses

Numerous devices composed mostly of alloys and plastic have been developed to aid in joint replacement efforts. Prosthetic replacements are now available for almost every joint in the body, and even a spinal segment can now be replaced. This field continues to rapidly expand, with a constant influx of new components and the outdating of others. Each is listed in the appropriate section by anatomy. Many of the prostheses listed may already be or soon will be obsolete. They are mentioned because they will still be found in some patients in the future and in their records. Chapter 13 discusses research efforts in internal prostheses.

The advent of a polymer called methyl methacrylate led to the development of new types of devices held firmly in place by polymers (not a glue). It is a cementlike substance that forms no chemical bonds but instead holds components to bones by space filling and locking effects. Methyl methacrylate usually has added barium sulfate to make the substance visible on radiographs. When applied, methyl methacrylate is soft and pliable, but it becomes very hard and firm within 15 minutes because of polymerization called polymethylmethacrylate (PMMA). Problems encountered with this method prompted further research and improvement in the development of joint resurfacing techniques.

The cement technique was originally a finger-packing process that was eventually called first-generation technique. The use of a gun, a cement-holding device similar to a caulking gun, was used in the second-generation technique. The use of a vacuum to help remove bubbles from the cement, thus strengthening the eventual cement construct, has been referred to as third-generation technique.

All internal prosthetic devices wear, resulting in the production of microscopic particles that eventually cause a cellular response that leads to bone absorption and prosthetic loosening. The terminology for general material applications for all prosthetics is listed here.

  • adhesive wear: the most common cause of polyethylene wear in hip replacement; microscopic particles release into joint because of the tendency for adhesion between the opposing surfaces.

  • alumina: ceramic material used for total joints.

  • annealing: heating below the temperature of ultra-high-molecular-weight polyethylene.

  • beaded: tiny cobalt chrome beads bonded to surface of implants for bone ingrowth.

  • big femoral head (BFH): technology starting with 36-mm size and larger.

  • cast components: larger grain size and softer.

  • ceramic-ceramic bearing: bearing consisting of two like ceramics articulating with each other.

  • computer-assisted orthopaedic surgery (CAS): assists in accurate placement of prosthetic components.

  • computer navigation: when intra-operative landmarks are registered to create a virtual model to assist in more accurate and precise placement of prosthetic components. This can be performed image-guided to corroborate intra-operative findings with existing imaging (e.g., radiographs, CT, or MRI) or imageless navigation.

  • crevice corrosion: breakdown of the metal that affects the grain structure, which ultimately leads to failure of the implant.

  • cross-linked ultra-high-molecular-weight polyethylene (UHMWPE): increased radiation to 10 megarads and elimination of free radicals causes cross-linking of polyethylene for greater wear resistance.

  • fibermetal: microtubular-like titanium coating of prostheses for bone ingrowth fixation.

  • forged components: smaller grain size and greater hardness.

  • fretting corrosion: corrosion occurring at the junction of two metal interlocking parts that have micromotion.

  • hemiarthroplasty: only one articular surface is replaced, leaving the native joint on the opposite side intact.

  • hybrid fixation: the use of cement fixation for one component of a total joint and bone ingrowth for the other component.

  • hypersensitivity reaction: allergic reaction related to metal ions that become attached to haptens.

  • keel: portion of prosthesis, typically a tibial tray that has flanges that extend into the metaphysis.

  • metal-metal bearing: bearing consisting of two metal surfaces articulating with each other. Concern is metal ion levels in blood, damage to surrounding soft tissues, and pseudotumor formation.

  • micromotion: when applied to implants, motion of 28–50 μm, which allows for bone ingrowth.

  • minimally invasive surgery (MIS): procedures done through smaller incisions.

  • modular components: many prosthetic components, particularly the femoral components of hip replacements, have different-sized interlocking parts to allow for different sizes and shapes of the femur; also called modularity.

  • oxidized zirconium: surface treatment that likely reduces surface wear of ceramic.

  • patient-specific instrumentation: custom cutting guides created from imaging (typically CT or MRI).

  • polymethylmethacrylate (PMMA): a relatively fast-setting plastic generated from methacrylate that acts as grouting agent in the fixation of prosthetic components.

  • press fit: design to have a firm fixation based on firm abutment against three points of bone canal margins. Typically these have porous coats for bone ingrowth.

  • prosthesis of antibiotic-loaded acrylic cement (PROSTALAC): a joint replacement component made of cement with high dose antibiotics used to treat periprosthetic joint infection,

  • remelting: heating above the melting temperature of ultra-high-molecular-weight polyethylene.

  • resection arthroplasty: removal of joint surfaces without prosthetic replacement; frequently used in the treatment of septic joint infections and prosthetic infections.

  • resurfacing arthroplasty: used mostly in hips, conserves the femoral head and neck by using a thin-walled acetabular component with typically metal on metal components.

  • robotic joint replacement: a type of computer-assisted surgery (CAS) in which a machine is used to assist in more accurate placement of the joint replacement components.

  • salvage procedure: descriptive of revision procedures with innovative approaches to large bone defects or other anatomic loss.

  • stress shielding: although more commonly applied to prosthetic devices, this term is applied to the effect of any implant in which there is loss of bone integrity caused by the biologic bone absorption secondary to the shield of stress by the implant.

  • stripe wear: caused by edge-loading of ceramic such as when the trunnion impinges on the acetabular rim, which has been identified to occur during certain activities (e.g., when rising from a chair or during stair climbing.

  • tantalum: a highly porous material with elastic modulus closer to bone allowing for initial stability.

  • taper: rounded top of the femoral stem component; designed as a slightly tapered cylinder that will accept a similarly female-shaped portion of the femoral head, which come in various sizes.

    • Eurotaper (12/14): taper designed with a 12-mm tip and 14-mm base.

    • Morse taper: specific type of taper used to accept femoral head component on the stem component.

  • third-body wear: wear caused by particles (cement or metal) between bearing surfaces.

  • third-generation ceramic: small grain size with increased density and each prosthesis proof tested to reduce likelihood of fracture.

  • total joint replacement: both articular surfaces are replaced with a prosthetic component.

  • trabecular metal: highly porous metal scaffold made of titanium or tantalum used as a coating for ingrowth on uncemented joint replacement components and augments. Also known as Hedrocel.

  • two-body abrasive wear: hard surface on opposing soft surface wear.

  • zirconium: ceramic material used for total joints.

Arthro- (Joints)

Anatomy of Joints

( Fig. 8-5 )

  • bursa sac: helps tendons and muscles to glide easily over bones at the joint outside the synovial fluid.

  • capsule: the general fibrous and ligamentous tissues that act as encasements and enclose the immediate joint area.

  • cartilage: the strong, smooth covering at the ends of the articular surface of bone. In highly mobile joints like the wrist, fingers, and elbows, this cartilage is called hyaline. In less mobile segments, such as the intervertebral disk, fibrocartilage is present.

  • meniscus: in the knee, a crescent-shaped fibrocartilaginous disk between the two joint surfaces. There are other menisci and meniscal-like structures in the body. The medial and lateral menisci of the knee receive the most surgical attention.

  • subchondral bone: named for the bone immediately next to the joint cartilage. Also called subchondral plate.

  • synovium: inner lining of a joint cavity that is a one- or two-layer cell membrane (synovial membrane) on a bed of fat. The synovial membrane normally produces and absorbs a clear synovial fluid, which lubricates and feeds cartilage surfaces.

Fig. 8-5Typical structure of diarthrotic joint. (From Hilt NE, Cogburn SB: Manual of orthopedics, St Louis, 1980, CV Mosby.)

Types of Joints

Joints are the places of union between two or more bones. All joints are not alike in structure and fall into the following categories according to function. The movable joints are diarthrodial joints that are a movable joint with a layer of fibrocartilage or hyaline cartilage that covers two opposing bony surfaces.

  • ball-and-socket j.: main points of articulation; femur to acetabulum of hip, humerus to glenoid of shoulder.

  • hinge j.: located in the elbows, fingers, and knees.

  • immovable j.: of orthopaedic concern, in the symphysis pubis and sacroiliac region.

  • synovial j.: two bones connected by fibrous tissue (capsules) with space between them and lined with synovial membrane.

  • weight-bearing j.: located in the lower spine, hips, knees, and ankles.

General Surgery of Joints

  • arthrectomy: excision of a joint.

  • arthrocentesis: needle puncture and aspiration of fluid from a joint.

  • arthroclisis: surgical breaking down of an ankylosis to secure free movement of a joint.

  • arthrodiastasis: distraction of a joint with an external fixator. When applied to the hip for avascular necrosis of the femoral head call a Segev p.

  • arthrodesis: a procedure to remove the cartilage of any joint to encourage bones of that joint to fuse, or grow together, where motion is not desired, for example, the spine. Also, an external fusion of a joint by means of a bone graft. The many types of arthrodeses are listed separately.

  • arthroereisis: a procedure to limit abnormal motion in a joint. Could be in any joint, but frequently referred to in the foot.

  • arthrokleisis: ankylosis of a joint by closure; production of such ankylosis.

  • arthrolysis: loosening adhesions in an ankylosed joint to restore mobility.

  • arthroplasty: reconstructive surgery of a joint or joints to restore motion because of ankylosis or trauma or to prevent excessive motion. This repair and reconstruction may use metallic, ceramic, polyethylene, or other implants.

  • arthroscopy (arthroendoscopy, endoscopy) ( Fig. 8-6 ): a surgical examination of the interior of a joint and evaluation of joint disease by the insertion of an optic device capable of providing an external view of the internal joint area. This technique represents a major advance in orthopaedic technology. The optical system is fiberoptic, giving the surgeon a high-resolution view of a joint, anywhere from a direct forward view to a view at 70 degrees to the end of the microscope, allowing the surgeon literally to see around corners. The arthroscopes vary in diameter from 2.7 to 5 mm. Miniature television cameras are attached directly to the arthroscope, allowing all operating room personnel to view the interior joint. With the advancement of arthroscopic surgery, a wide variety of instruments has made it possible to replace or repair cruciate ligaments, remove synovium and plicas, repair peripheral tears, excise meniscal tissue, remove loose bodies, shave cartilage, and do many other procedures. The arthroscope is now used in almost all joints of the extremities. It is also used for release of ligaments such as the carpal and tarsal tunnels.

    Fig. 8-6Arthroscope outside of sleeve that is used during surgery; close-up view of 30-degree angle for viewing difficult to see areas. (Wide-angle arthroscope, 4-mm diameter, 30-degree angle optic. Courtesy Arthrex, Inc., Naples, FL.)

  • arthrotomy: surgical incision into a joint for exploration and removal of joint material; usually refers to knee exploration but can apply to any joint.

  • arthroxesis: scraping of diseased tissue from the articular surface of bone.


Three Basic Categories of Arthrodeses

  • compression a.: a general class of arthrodeses in which the pins on either side of the joint have some external compression device; the appliance is removed after fusion takes place.

  • extraarticular a.: fusion of the joint outside the joint capsule; rarely used.

  • intraarticular a.: fusion of a joint all within its capsule, with or without intraarticular bone grafts.

Specific Arthrodeses

  • Abbott-Fisher-Lucas a.: two-stage hip fusion that includes a delayed femoral osteotomy.

  • Baciu and Filibiu a.: intraarticular ankle fusion using dowel bone graft taken from the joint to include the medial and a portion of the lateral malleolus. The graft is rotated 90 degrees and reinserted.

  • Badgley a.: intraarticular and extraarticular hip fusion, using anterior iliac crest of bone.

  • Benaroch a.: for pediatric destructive disease; an open arthrodesis with anterior iliac crest pedicle graft.

  • Blair a.: a tibiotalar fusion, using an anterior sliding tibial graft.

  • Bosworth a.: a method of fusing the hip following tuberculosis infection.

  • Brett a.: extraarticular shoulder fusion, using tibial graft.

  • Brittain a.: four procedures have this name: (1) intraarticular knee fusion using anterior tibial grafts, (2) extraarticular hip fusion requiring a subtrochanteric osteotomy and tibial bone graft, (3) extraarticular graft to the medial side of the humerus of shoulder, and (4) intraarticular fusion of the elbow using two crossed intraosseous grafts.

  • Campbell a.: extraarticular fusion of the ankle and subtalar joint.

  • Chandler a.: intraarticular and extraarticular hip fusion, using the deep portion of the greater trochanter.

  • Charnley a.: intraarticular type of ankle or knee fusion, using a temporary metallic external compression clamp.

  • Charnley and Henderson a.: intraarticular and extraarticular fusion of the shoulder, using the glenoid and acromial surface abutting a split humeral head.

  • Chuinard and Petersen a.: of the ankle, using a wedge of iliac bone.

  • Compere and Thompson a.: intraarticular hip fusion, using iliac crest and wing for bone graft.

  • Davis a.: intraarticular and extraarticular hip fusion, accomplished by using a live pedicle of iliac crest.

  • Ghormley a.: intraarticular and extraarticular hip fusion, using anterior iliac crest graft.

  • Gill a.: extraarticular and intraarticular fusion, using acromion bone graft from and to the shoulder.

  • Henderson a.: intraarticular and extraarticular hip fusion, using detached iliac cortical bone graft.

  • Hibbs a.: intraarticular and extraarticular hip fusion, using greater trochanter as a graft.

  • Horwitz and Adams a.: ankle fusion, using the distal fibula as a graft.

  • John C. Wilson a.: intraarticular and extraarticular hip fusion, using an iliac side graft.

  • Key a.: knee fusion, using anterior inlay bone graft.

  • Kickaldy and Willis a.: intraarticular and extraarticular hip fusion, using iliac crest bone from the ischium to the inferior neck.

  • King procedure a.: intraarticular hip fusion, using iliac and tibial bone grafts.

  • Kuntscher modified a.: knee arthrodesis, using a bridging intramedullary rod.

  • Lucas and Murray a.: knee fusion, using patella for bone graft and held by an internal plate.

  • Marcus, Balourdas, Heiple a.: chevron-shaped tibiotalar fusion, using inlay graft taken from medial and lateral malleolus.

  • Matta p.: for pediatric hip destruction; anterior fixation of hip arthrodesis.

  • Müller a.: intraarticular shoulder fusion, using bent plates for fixation.

  • Pagnano and Cabanela a.: for hip degeneration; includes hip compression screw fixation.

  • Potter a.: knee fusion, using a retrograde tibial rod and graft from the distal tibia.

  • Putti a.: (1) knee fusion, using anterior tibial graft; (2) extraarticular fusion, using the acromion of the scapula; (3) an intraarticular fusion of the shoulder.

  • Scalise and Iannotti p.: for failed shoulder prostheses; shoulder arthrodesis.

  • Schneider a.: intraarticular hip fusion, using innominate osteotomy with greater trochanter for a bone graft.

  • sliding a.: anterior ankle fusion, using tibial bone.

  • Smith-Petersen a.: technique for fusion of the sacroiliac joint.

  • Stamm a.: intraarticular hip fusion, using free iliac crest bone grafts.

  • Staples a.: intraosseous and extraosseous elbow fusion.

  • Steel iliofemoral a.: for proximal femoral deficiency; iliofemoral fusion to have knee function as hip for lower limb prosthesis.

  • Steindler a.: intraarticular fusion of the shoulder or the elbow, using posterior bone graft.

  • Stewart and Harley a.: for fusion of ankle, using lateral and medial malleoli as grafts.

  • Stone a.: intraarticular hip fusion, using a split acetabulum and bent plate from the ilium to the femoral neck.

  • Trumble a.: extraarticular hip fusion, using a tibial graft from the ischium to the femur.

  • Watson-Jones a.: intraarticular and extraarticular hip fusion, using a nail and iliac crest graft; also, a shoulder fusion, using a piece of acromion.

  • White a.: intraarticular hip arthrodesis, using posterolateral approach and iliac bone graft.

  • Wilson procedure a.: extraarticular fusion of the elbow.

  • Wolf blade plate a.: ankle arthrodesis performed with a specifically designed blade plate internal fixation device.

Chondro- (Cartilage)

Cartilage (L. gristle ) is a fine, glistening, resilient, nonvascular fibrous connective tissue that absorbs shock and facilitates the mechanics of joint motion. All mobile joint surfaces contain cartilage. Perichondrium is a connective tissue that covers cartilage in some places. Cartilage cells (chondrocytes) are widely separated and surrounded by matrix, also (chondromucoid) known as ground substance, composed of collagen and mucopolysaccharides. In the embryo, cartilage forms the temporary skeleton and is important to growth in providing the model in which most of the bones develop. Then it is called ossifying or precursory cartilage.

Cartilage cannot be seen on radiographs; if open space is apparent between two bones on radiography, cartilage is present. However, if the radiograph shows two bones touching at a joint, such as the femur on the tibia, osteoarthritis and dissolution of the cartilage in that joint may have occurred.

Types of Cartilage

  • articular c.: thin layer of hyaline cartilage on articular surface of bones in synovial joints; also called arthrodial c. and diarthrodial c.

  • calcified c.: in which granules of calcium phosphate and calcium carbonate are deposited in interstitial substance; seen adjacent to subchondral bone and at the terminus of the physis.

  • cellular c.: composed almost entirely of cells with little interstitial substances.

  • connecting c.: connects surfaces of an immovable joint; also called interosseous c.

  • elastic c.: yellow opaque flexible substance (more so than hyaline) in which cells are surrounded by a territorial capsular matrix, outside of which is an interterritorial matrix containing elastic fiber networks, collagen fibers, and ground substance; also called reticular c. and yellow c.

  • fibrocartilage: contains types I and II collagen fibers with a strongly basophilic ground substance in area of chondrocytes; seen in the meniscus, labrums, some tendon attachments.

  • floating c.: detached piece of cartilage on medial or lateral condyle of femur or on patella.

  • hyaline c.: somewhat elastic, semitransparent cartilage, characterized by type II collagen and proteoglycan aggrecans. Seen in movable joint surfaces and the physis (growth plate).

Surgical Procedures on Cartilage

  • articular cartilage implant (ACI): cells harvested from a non–weight-bearing portion of the joint are suspended in cell culture for cell division. Weeks later, the expanded mass of cells are placed in the defect with a covering of neighboring periosteum. Also called articular cartilage transfer (ACT).

  • chondrectomy: surgical removal of cartilage.

  • chondrodiastasis: for limb-length discrepancy; closed, gradual, and progressive distraction of the growth plate by using an external bone fixation device.

  • chondroplasty: plastic surgery on cartilage by repair of lacerated or displaced cartilage.

  • chondrosternoplasty: surgical correction of funnel chest.

  • chondrotomy: dissection or surgical division of cartilage.

    • synchondrotomy: incision and division of an articulation that has no appreciable mobility and in which cartilage is the intervening connective tissue.

  • microfracture: piercing of the subchondral bone base of a cartilage defect to promote development of a hematoma and healing with fibrocartilage.

  • mosaicplasty: removal of plugs of cartilage and bone from a limited–weight-bearing portion of the joint to be placed in the area of a defect. Also called osteoarticular cartilage transfer (OATS)

  • osteochondral allograft: a living graft combining articular cartilage and bone to replace damaged joint surfaces.

  • shell osteochondral allograft: donor-intact cartilage and subchondral bone is harvested from the same location as similar-sized donor and implanted in defect site. The term shell refers to the relatively thin 5-mm shell of bone that distinguishes this procedure from larger bony segments.

Capsulo- (Capsule)

A capsule is the circumferential sleeve surrounding a joint composed of a tough band of fibrous and ligamentous tissues. It may be referred to as a joint capsule or a capsular ligament.

Surgical Procedures on the Capsule

  • capsulectomy: excision of a joint capsule; most commonly done on the hip.

  • capsulodesis: imbrication of a capsule (see Chapter 10 ).

  • capsuloplasty: plastic surgery on a joint capsule.

  • capsulorrhaphy: suturing of a joint capsule. If used by itself, the term implies a procedure on the shoulder (glenohumeral joint) because this joint commonly has soft tissue reconstructions.

  • capsulotomy: incision into a joint capsule; also called capsotomy.


A bursa (sac or saclike cavity) is filled with viscid fluid and situated in places in tissue where friction would otherwise develop. Bursae act as cushions, relieving pressure between moving parts such as an anserine bursa, a goose-foot sac found between tendons of the sartorius, gracilis, and semitendinous muscles and the tibial collateral ligament. A bursal sac is easily recognized during surgery and is involved in only four procedures.

  • bursectomy: excision of a bursa.

  • bursocentesis: puncture and removal of fluid from a bursa.

  • bursoscopy: endoscopic visualization of a bursa, most commonly hip or shoulder.

  • bursotomy: incision into a bursa.

Other Specific Tissues

The entire musculoskeletal system is made up of connective tissues, that is, cellular and organic materials that establish structure and shape. Bones and joints receive the most attention in orthopaedic surgery and are, therefore, listed separately.

All connective tissues have, to some degree, cohesion that is supplied by a protein structure called collagen. Collagen, in its most familiar form, is a household product, gelatin. However, when combined with other chemical and cell elements, it is the basic molecular matrix of bone, cartilage, tendons, and many other tissues. The connective tissue cells are the following.

  • adipose tissue: fatty tissue.

  • chondroblasts: cells that form cartilage.

  • chondroclasts: cells that remove cartilage.

  • chondrocytes: cartilage cells.

  • fibroblasts: cells that predominantly form collagen.

  • fibrocytes: cells seen in tendons, ligaments, and similar structures.

  • histiocytes: cells involved in removal of cellular or chemical debris; a type of phagocyte.

  • myoblasts: muscle-forming cells.

  • myocytes: muscle cells, voluntary (striated) and involuntary (nonstriated).

Myo- (Muscle)

Muscle is the contractile tissue essential for skeletal support and movement. The anatomic features of muscles with associated tissues and surgery are presented here.

Muscle fibers are composed of small bundles of cells combined to form distinct muscular units. Terms often related to muscle include actin, myosin, sarcomere, nerve spindle, motor unit, neuromuscular junction, and spindle cell.

The smooth, coordinated way in which muscles work together in the execution of a movement is called synergy (syn- [together] + ergon- [work]). In particular, the muscles that play the part of synergists during any particular movement are concerned with obviating any unwanted movement that might result from the action of the prime movers or agonists. Muscles that pull in the opposite direction are called antagonists. Synergist muscles are usually classified as corrective if they obviate such unwanted movements, and fixative if they fix the point proximal to that at which the movement is taking place. A concentric contraction is a contraction while the muscle is shortening. An eccentric contraction is a contraction while the muscle is lengthening. Muscle insertion is the attachment of a muscle or its tendon to the part of the skeleton that the muscle moves when it contracts. Muscle origin is a fixed attachment or anchor of muscle allowing a muscle to exert power when it contracts. The many muscle groups are named and illustrated in Fig. 8-7 .

Fig. 8-7Muscular system, A, Anterior view.

Surgical Procedures on Muscles

  • myectomy: excision of a portion of muscle.

  • myoclasis: intentional crushing of muscle; rare.

  • myomectomy (myomatectomy): surgical removal of tumors with muscular tissue components.

  • myoneurectomy: surgical interruption of nerve fibers supplying specific muscles; used for patients with cerebral palsy.

  • myoplasty: plastic surgery on muscle in which portions of partly detached muscle are used for correction of defects or deformities.

  • myorrhaphy (myosuture): muscle repair by suture of divided muscle.

  • myotenontoplasty: surgical fixation of muscles and tendons.

  • myotenotomy: surgical division of a tendon from muscle.

  • myotomy: incision or dissection of muscle or muscular tissue.


Aponeurosis is the name given to the end of a muscle that becomes a tendon. This muscular component is a white, flattened, ribbonlike tendon expansion that connects muscle with the parts it moves.

Surgical Procedures on Aponeuroses

  • aponeurectomy: excision of the aponeurosis.

  • aponeurorrhaphy: repair and suture of muscle and tendon; fasciorrhaphy.

  • aponeurotomy: surgical incision into the aponeurosis.

Teno- (Tendons)

The extension of muscle into a firm, fibrous cord that attaches into a bone or other firm structure is a tendon. Some muscles have a tendon at both ends, some have direct attachment to bone at one end, and a few attach directly to bone at both ends and have no tendon.

A common tendon serves more than one muscle, such as a conjoined tendon that is found in the inguinal region. The tendons that receive the most attention are the following:

  • Achilles t.: the common tendon of the gastrocnemius and soleus muscle inserted into the medial posterior surface of the calcaneus; also called calcaneal t. or tendo calcaneus, heel t.

  • hamstring t.: one of the tendons that cross the popliteal fossa laterally and medially. The inner hamstring includes tendons of the gracilis and sartorius muscles, and the outer hamstring is the tendon of the biceps flexor femoris muscle.

  • patellar t.: anterior or inferior ligamentum patellae.

  • rotator cuff t: tendons of muscles that surround the shoulder joint, arising from the scapula and attaching to the proximal humerus.

  • Sharpey fibers: fibers of a tendon attached to bone that actually penetrate the periosteum and cortex of bone, and thus make a very strong attachment.

Surgical Procedures on Tendons

The nomenclature of surgical procedures on tendons has a certain amount of overlap, because several prefixes are used: teno-, tendo-, and tendino-. Therefore the same surgical procedure may have several spellings. The preferred term for a surgical procedure is listed first, with the related term appearing after the definition.

  • tendon release: surgical transection of a tendon, with or without repair.

  • tenectomy: excision of a lesion (ganglion or xanthoma) of a tendon or of a tendon sheath.

  • tenodesis: tendon fixation by suturing proximal end of a tendon to the bone or by reattachment of the tendon to another site.

  • tenolysis: surgically freeing a tendon from adhesions; also called tendolysis.

  • tenomyoplasty: procedure involving repair of tendon and muscle; also called tenontomyoplasty.

  • tenomyotomy: excision of a portion of tendon and muscle.

  • tenonectomy: excision of a portion of tendon with or without excision of a portion of tendon to shorten it.

  • tenontomyotomy: incision into the principal tendon of a muscle, with partial or complete excision of that muscle.

  • tenoplasty: surgical repair of a ruptured tendon; also called tendoplasty, tendinoplasty, and tenontoplasty.

  • tenorrhaphy: union of a divided tendon by a suture; also called tenosuture and tendinosuture.

  • tenosuspension: surgical repair that fashions a soft tissue sling to hold the tendon in a specific place.

  • tenosynovectomy: resection or excision of excessive synovial lining within the tendon sheath.

  • tenotomy: incomplete or complete division of a tendon, as in clubfoot; also called tendotomy.

Desmo- (Ligaments)

Ligaments are bands of strong fibrous connective tissue that bind together the articular ends of bones and cartilage at the joints to facilitate, stabilize, or limit motion. Also, they give support and attachment to fascia, viscera, and muscles. An accessory ligament supports another ligament on the lateral surface outside the joint capsule where excessive motion occurs. Because ligaments tie bones together, the prefix syn- (together) is used with desmo- (ligament) for ligament surgery. Syndesmosis is the name for an articulation in which the bones are united by ligaments (e.g., the distal tibiofibular articulation).

Surgical Procedures on Ligaments

  • desmotomy: surgical division of a ligament or ligaments.

  • ligamentotaxis: use of strength of ligaments to bring about reduction of fracture fragments by using external skeletal fixation.

  • syndesmectomy: excision of a ligament or portion thereof.

  • syndesmopexy: surgical fixation of a dislocation by using the ligaments of a joint.

  • syndesmoplasty: ligaments sutured together.

  • syndesmorrhaphy: suture or repair of ligaments.

  • syndesmotomy: dissection or cutting of ligaments.


Fasciae (pronounced fash*-e-e) (fascia, sing.) are sheets of dense connective fibrous tissue that act as a restricting envelope for muscular components and bind groups of muscles, blood vessels, and nerves into bundles. Generally, the fascia does not play any role in the movement of joints and bones. The exception to this is the fascia lata of the outer thigh; this fascia has its own muscle, the tensor fascia lata, that, when tightened, will pull through the fascia to points across the knee.

Surgical Procedures on Fasciae

  • fasciaplasty: plastic surgery of fascia; also called fascioplasty.

  • fasciectomy: excision of strips of fascia.

  • fasciodesis: suturing a fascia to another fascia or tendon.

  • fasciorrhaphy: suturing and repair of lacerated fascia; also called aponeurorrhaphy.

  • fasciotomy: surgical incision or transection of fascia, commonly done for forearm and leg injuries, in which the pressure in the compartment surrounded by the fascia has become very high.

Neuro- (Nerves)

Nerves are cordlike structures that convey electrical impulses between a part of the central nervous system and some other region of the body. Structural components of the nerves include epineurium, perineurium, nerve sheath, axon, Schwann cell, and myelin. Innervation refers to the nerve supply to any tissue. Nerves are usually named for the anatomic area involved. Hilton law states that a nerve trunk that supplies any joint supplies the muscles moving that joint and the area over the skin over that joint.

Orthopaedic Surgical Procedures on Nerves

  • Mackinnon and Colbert p.: a double fascicular transfer, neurotization of axillary nerve with radial nerve or suprascapular nerve with spinal accessory nerve.

  • Mackinnon and Novak p. for reconstruction of high ulnar nerve injuries; distal anterior interosseous transfer to the deep motor branch of the ulnar nerve.

  • Mellesi cable graft: for neuroma excision and replacement with grafts of specific length of fascicular gap.

  • neurectomy: resection of a segment of a nerve.

  • neurolysis: destruction of a perineural adhesion by a longitudinal incision to release the nerve sheath.

  • neuroplasty: plastic repair of a nerve.

  • neurorrhaphy: suture of a severed nerve; repair.

  • neurotomy: division of a nerve or nerves.

  • neurotripsy: surgical crushing of a nerve.

  • rhizotomy (radicotomy, radiculectomy): procedure dividing the nerve roots close to their origin from the spinal cord; rhizo- refers to root of the spinal cord. Typically performed to decrease muscle tone in cerebral palsy patients.

Vascular (Blood Vessels) System

( Fig. 8-8 )

Dec 24, 2021 | Posted by in ORTHOPEDIC | Comments Off on Anatomy and Orthopaedic Surgery
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