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Preoperative Planning Syme Amputation In patients where the tibial length at skeletal maturity is expected to be equal to that of the opposite side medications known to cause weight gain order neurontin overnight, a Boyd amputation or timed epiphysiodesis should be considered to accommodate the height of the prosthetic foot to achieve equal limb lengths at maturity medicine images buy cheapest neurontin and neurontin. With traction and manipulation of the pieces, the medial wall is reduced and pinned with axial Kirschner wires that travel just inside the medial wall of the calcaneus. The distal femoral segment is reduced to the plate and fixation is completed with three or four screws. As the scapula is reduced, the somatosensory evoked potentials and the transcranial electrical motor evoked potentials should verify the function of the nerves to the arm. Thoracoscopic techniques for the treatment of scoliosis: early results in procedure development. The Kirschner wire or flexible nail must be long enough to engage the epiphyseal fragment and still protrude enough distally to facilitate rotation of the wire or nail with a T-handle. Relief of joint pain, whether unifocal or bifocal, will allow the surgeon to counsel the patient on further reconstructive treatment. They can be checked and redressed if concern exists, and pin care with half-strength peroxide is helpful. Aglietti and coworkers1 reviewed 14 children (16 knees) treated with transarticular drilling after 1 year of conservative management and found all cases progressed to healing after treatment. External bone stimulation can also be considered early (for acceleration of fresh fracture healing) or late (as an adjunct to nonunion surgery) in the treatment course. Increases in height during this period average 2 cm per year, and by the age of 5, two thirds of the final sitting height is achieved. The lateral nail (nail entering through the lateral cortex of the femur) should end at the apophysis of the greater trochanter. To support an uncemented cup, the remaining bone stock should allow for at least partial inherent stability of the reamer or trial. That length minus the amount to be resected is the length of intramedullary rod to be used. Checking Alignment and Mechanical Axis Once all the pins are inserted, a Bovie cord is used to check the mechanical axis of the limb. The outer table of the ilium is subperiosteally dissected, and the hip abductor muscles are lifted from anterior to posterior. Factors influencing mortality in cemented bipolar hemiarthroplasty include cardiac history, residence in a nursing home, chronic pulmonary disease, elevated serum creatinine, pneumonia, history of myocardial infarction, duration of surgery, and gender. Deformity correction at this level can stretch or compress the anterior tibial artery because of its proximity to the tibia at that level. It can be injected into the gastrocnemius muscle bellies in an attempt to decrease tone. The femoral osteotomy is just below the lesion, to provide disease-free bone stock for fixation of the proximal femur replacement. The lateral cortex of the ileum is assessed from its crest by detaching a small portion of the periosteum, allowing the insertion of a blunt retractor to protect the abductor muscles during the iliac osteotomy. The proximal portal position is most important, since the most proximal two screws are often placed in small vertebral bodies and have significant coronal angulation, and retraction of the scapula makes this portal difficult. Fluoroscopy is used to ensure that the plates are flush and securely fastened to the bone. Peritrochanteric metastatic lung cancer treated with screw and side-plate construct that failed within 4 months. The bump may be removed after lateral fixation for easier access to the medial side. After the insertion of one pin in each clamp, the remaining pins are inserted for a total of eight half-pins (two pins per clamp).

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Patients with other severely affected joints medications for ptsd purchase neurontin 100 mg fast delivery, difficult home environments medicine 2016 purchase line neurontin, or poor social support may require a brief period of inpatient rehabilitation. Older children may be able to comply with formal two-point discrimination testing. Both still and video photography are helpful to record preand postoperative appearance and to document function. The surrounding soft tissues, in particular posteriorly, must be protected with blunt retractors. The reference array should be detected by the cameras both in the supine and ateral positions during the operation. Intraoperative C-arm view showing the guidewire at a 110-degree angle to the femoral shaft. The medial skin flap should be kept as thick as possible by keeping the dissection just superficial to the extensor mechanism. If the osteotomy is larger than 7 degrees, bone graft is needed to fill the defect in opening wedge techniques. It should make it possible to determine the level and localization of the osteotomy, as well as entry point and direction of the implant in relation to reference points that can be identified intraoperatively. The direction of the blade, which also was determined by the preoperative drawing, can now be measured with quadrangular positioning plates and marked with a Kwire inserted into the trochanter cranial to the cortical window. The lateral release is extended distally to the lateral aspect of the patellar tendon. It is a durable solution that lasts a lifetime and allows for a stable, painless extremity for ambulation. Previous knee fusion rods had different diameters for the femur and tibia but are no longer commercially available. Malunion may occur in unstable fractures treated nonoperatively or in those with premature growth arrest. With the lower extremity held in this position, the guide pin can be inserted parallel to the floor. If one is to err, one would prefer too little tension than too much, as the transfer tends to tighten over time, particularly if performed in a young child with significant remaining growth potential. The patient is allowed to bear weight to tolerance, and early progression to range of motion is encouraged. The talus lies sandwiched between the malleoli, stabilized by the deltoid ligament medially and the talofibular and calcaneofibular ligaments laterally. However, if revision is not deemed a safe option for medical, psychosocial, or other reasons, management is similar to that for a patient with endstage knee arthritis. One-stage revision surgery of the infected hip: A minimum 10-year follow-up study. Prospective matched-pair analysis of hydroxyapatite-coated and uncoated femoral stems in total hip arthroplasty: a concise follow-up of a previous report. On the third or fourth postoperative day, the patient should achieve flexion of at least 70 degrees and can be discharged with a walker or crutches. The bolt is loosened, a dynamization clip is inserted between the rod vise plates, and the bolt is retightened. The cranial anchors and transverse connector are tightened first, followed by the caudal anchors and transverse connectors. While introducing half-pins, it is necessary to flex the knee to avoid placement across the tendon and muscle (ie, biceps femoris, semitendinosus, semimembranosus). The physical examination should focus on assessing initial displacement and skin condition (ie, open injury), as well as swelling of the compartments. Intuitively, the patient should be supine if other surgery is to be performed on the foot and ankle. The first step is reaming the intramedullary canal of the tibia and femur to 12 mm. The medial approach described by Ludloff3 accesses the hip in the interval between the pectineus and the adductor brevis. A high-speed burr is used to remove high points or areas of impingement to allow the stem to seat at the desired level.

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It is recommended symptoms 0f ms purchase discount neurontin, therefore symptoms 13dpo buy generic neurontin 300mg on-line, that the anterior cortex be osteotomized first and the osteotomy completed posteriorly thereafter. This view will demonstrate the medial wall and show the relation of the superomedial fragment to the tuberosity. As one proceeds from distal to proximal in the lumbar spine, the lateral elements are palpated and with the use of electrocautery, the soft tissues are incised to bone. The radial digital nerve obliquely crosses the tendon sheath just proximal to the A1 pulley, and the ulnar digital nerve runs parallel to the tendon immediately alongside the A1 pulley. A positive result, indicative of infection, is considered when there are more than 5 polymorphonuclear leukocytes per high-power field. It should be performed just below the insertion of the tibial tubercle, decreasing the risk of damage to the nearby physis and joint line. The term "congenital trigger thumb" is a misnomer, as it has yet to be detected at birth in several large series prospectively examining a combined 14,581 newborns in three countries. The three-dimensional configuration of the distal femoral physis contributes to the considerable energy required to fracture through the distal femoral physis, and the complex geometry increases the likelihood for violation of the physeal cartilage barrier between epiphyseal and metaphyseal bone, thereby increasing the risk of partial physeal bar formation after injury. Physical examination should include: Direct palpation over the base of the fifth metatarsal: Pain in this region increases suspicion of injury. The transverse osteotomy at this level heals rapidly and permits the use of strong internal fixation (blade plate), obviating the need for casting or any other external immobilization. The alignment rod is relied upon to verify the amount of opening of the osteotomy and the change in the mechanical axis. The appearance of the deformity is the major concern for the parents and patient, as there is little functional deficit. The posterolateral aspect of the tibial component must clear the posterolateral femoral condyle. Not all tumors that metastasize from the prostate to bone are blastic in nature, however. Thus, upper and lower curves should be considered together when contouring the rods. Stinchfield test: groin pain or weakness may indicate intra-articular hip pathology. If the tibia is in valgus and external rotation, the iliotibial band should be divided at this point. The scapula can now be drawn inferiorly and reduced to a more normal anatomic level. However, given the importance of independent digital motion-particularly in the current keyboard-driven digital age- nonoperative treatment of simple complete syndactyly is not recommended. Once skeletal maturity is reached, the orthotic use is recommended for sports and high-stress activities. Cement fixation may also be the best option in pathologic bone associated with tumor or radiation, or in any other situtation in which bone in- or ongrowth cannot be anticipated. Functional impairment and pain are unusual complaints, except in the case of active triggering. A ruler or magnification markers can also be placed next to the limb to allow more accurate measurement of limb length. The level of the osteotomy is determined by aiming at the cranial extension of the lesser trochanter. The anterior periosteum is usually thinner than the posterior, often leading to hinging of the fragments posteriorly and possible entrapment of the periosteum anteriorly. The handle of the osteotomy wedge is removed, and the wedge trial is placed between the tines to confirm the size of the osteotomy plate to be used. Accurate prediction of angular correction after physeal bar resection is not possible, making it very difficult to know with certainty the degree of osteotomy angular correction to perform. Subsequently, the Charnley retractor is removed, and the tensor fascia lata and gluteus maximus fascia are reapproximated. It may be necessary to grasp the rod through the pseudarthrosis to disengage the two sections. In the acute fracture there is a sudden onset of pain and it is difficult to ambulate. This wire enters the fibular head (just distal to the proximal fibular growth plate), traversing the tibia and exiting through the anteromedial tibial cortex.

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Femoral neck fractures in young patients typically are the result of high-energy mechanisms symptoms stomach flu cheap neurontin amex. The surgeon should view the Canale image intraoperatively with C-arm fluoroscopy (flexed knee treatment alternatives discount neurontin 300mg without prescription, everted foot in equinus and C-arm tube directed 15 degrees caudad). Of key importance is identification and release of the ileotransverse ligament traversing between the iliac wing and the L5 transverse process. For a patient over the age of 40 years, with no known history of metastatic carcinoma to bone, the osteophilic malignancies mentioned earlier must be considered and evaluated as described. After successful use in the treatment of pediatric femur fractures, the elastic intramedullary nail technique has also been successfully applied to the tibia. Contractures and angular deformity of the released digits may occur owing to linear scars on the radial or ulnar aspects of the fingers. The acetabulum develops at the junction between three embryologically distinct bones-the ilium, ischium, and pubis- which fuse at the triradiate cartilage during adolescence. The indications for proximal femoral replacement were as follows: Periprosthetic fracture: 20 patients Reimplantation because of a deep infection: 13 patients Failed arthroplasty: 13 patients Nonunion of an intertrochanteric fracture: 1 patient Radiation-induced osteonecrosis with a subtrochanteric fracture: 1 patient Three patients died before the minimum 2-year follow-up interval had elapsed, and two additional patients were lost to follow-up. This is in contrast to the lumbosacral facet joint, which is flat and more coronally oriented and acts to resist shearing forces through the joint. Bone impaction grafting combined with a cemented polyethylene cup allows for the restoration of the hip center and normal hip biomechanics. An initial rough cut of the femoral neck can be performed in line with appropriate preoperative templating. To prevent loosening, the graft can be reinforced and retensioned after fixation by passing a nonabsorbable suture through bone at the point at which the graft loops over the intermuscular septum. When available, a pedobarograph may be useful for documenting pathologic foot stresses. The femoral head is levered out posteroinferiorly, leading to a "contrecoup" lesion on the femoral head and acetabulum. Sinus tarsi approach with trans-articular fixation for displaced intra-articular fractures of the calcaneus. An open capsulotomy to look at the articular cartilage may prove to be beneficial. This fascial incision is extended distally to join the anterior margin of the fascia lata that was previously exposed. The mechanical axis is drawn from the center of the femoral head to the center of the knee joint, whereas the anatomic axis is the central axis of the femoral shaft. The radial nerve enters the anterior compartment of the arm in the distal third of the upper arm and travels between the brachialis and brachioradialis over the anterolateral distal humerus before it enters the supinator muscle in the proximal forearm. Posterior cruciate ligament-retaining, posterior stabilized, and varus/valgus posterior stabilized constrained articulations in total knee arthroplasty. The humerus is approached through a small deltoid-splitting incision to expose the greater tuberosity. It is not uncommon to see patients presenting with neurologic symptoms, which can vary from minor sensory or motor disturbances to established myelopathy. Lengthening and Exchange Lengthening of the dual rod construct may be performed as either an in- or outpatient procedure with neural monitoring for patients with normal neurologic function. Because a deformed femoral head or osteophytes around the femoral head and neck may make it difficult to recognize the actual state and relation of the femoral head and neck junction, excessive osteophytes should be removed carefully before femoral pinning. Late hematogenous infection presents with sudden onset of pain in a previously well-functioning prosthesis. Knee flexion just before the quadriceps tenotomy (F) and after the tenotomy (G,H). The knee fusion site is visualized during the compression to ensure good bone contact and to make sure there is no soft tissue interposition at the bone ends. The procedure is completed by placing bone graft lateral to the implants along the transverse processes from L4 to the sacrum. Guidewires can be inserted at the most cephalad portion of the osteotomy, directed toward the inner wall just above the triradiate cartilage.

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Often it has been present since the time of the initial hip replacement procedure medications jock itch generic neurontin 600 mg with mastercard. Galeazzi procedure patients have similar rehabilitation due to solid fixation if the tendon is sewn to itself symptoms tracker cheap neurontin 300mg overnight delivery. The final component is cemented into place after tibial preparation is complete, and excess cement is removed after the assembled tibial component is impacted into place. The stemmed tibial component was cemented into the implanted tibial cone and stems were press-fit in four knees and cemented in six knees. The calcaneus is fractured by a combination of shear and compression forces generated by the talus descending upon the calcaneus. Midshaft transverse fractures are at a higher risk of refracture when treated with external fixation compared to other methods of stabilization. Physical therapy is useful for obtaining range of motion, as well as initiation of quadriceps activation and strengthening. This limits the period of the load carried by the plate and the potential for failure. The proximal femur is formed by the femoral epiphysis and the trochanteric apophysis, both of which ossify by 16 to 18 years of age. At this point an arthroscopic basket or a meniscal knife can be used to incise and remove the meniscus coronally from the notch toward the body of the meniscus. The posterior facet is reduced under direct vision, and the reduction is confirmed with fluoroscopy. The use of pulsatile lavage can reduce that risk by removing fat and marrow from the femoral canal. The S1 nerve roots are often found draped over the sacrum, and again care should be taken that adequate space exists for their displacement after reduction. The gracilis muscle is innervated by the obturator nerve and has its origin on the inferior pubic ramus and its insertion on the anteromedial aspect of the proximal tibia. The shoulder is rotated and the tips of the pins should appear to approach the joint surface and then withdraw with continued rotation. The diameter of the nail is predetermined by measuring the isthmus of the femoral shaft. Bone loss with revision total knee arthroplasty: defect classification and alternative for reconstruction. This osteotomy allows for excellent lateral coverage, but only a limited amount of anterior coverage can be achieved. Patients with symptomatic osteolysis or loosening of the tibial component usually describe gradual onset of pain that is worse with startup type of activities such as arising from the bed or getting out of a chair or a vehicle. The appropriate length of the female nail is verified with the C-arm, as previously discussed. In such cases, we use hip arthroscopy to precisely address the intra-articular disease (eg, labrum, articular cartilage), followed by a limited open osteochondroplasty to correct the femoral-sided impingement deformity. Various combinations of augments and polyethylene liners should be tried until the optimal combination is found; this may take a considerable amount of time to achieve. The injuries are infrequent and the fracture anatomy is partially concealed by adjacent osseous structures. This includes acutely displaced fractures as well as originally nondisplaced fractures that displace during early follow-up. The surgeon should be familiar with the prosthesis and all of the available options and idiosyncrasies. Gabriel and associates9 reported the results of 29 patients who underwent 56 physeal procedures with a percutaneous epiphysiodesis. The tendon is rerouted to the radial aspect of the Lister tubercle and passed subcutaneously around the abductor pollicis longus and extensor pollicis brevis tendon. This is achieved by the use of hypotensive regional anesthesia with mean arterial pressure in the range of 45 to 70 mm Hg, and pulse-irrigation to remove fat and blood followed by drying with a sponge, with or without local use of epinephrine.

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Analysis of vertebral morphology in idiopathic scoliosis with use of magnetic resonance imaging and multiplanar reconstruction treatment modalities buy discount neurontin 100 mg on-line. The typical reduction order is first to correct any superomedial fragment subluxation treatment 1st 2nd degree burns cheap 300 mg neurontin amex. If the extremity is significantly short, these incisions become one extended approach. Full-length radiographs of both legs on the same cassette from the hips to the ankles are ideal to assess areas of fractures and degree of deformity. The surgeon places his or her index finger into the sciatic notch and then aims the rebar screw or pin parallel to the notch into the posterior column of bone toward the sacral ala. A full-thickness quadriceps tendon graft 6 to 8 mm wide is obtained, with attachment to the patella maintained at its widest portion. The inner and outer wall cuts should be on the same level and the two cuts should be about the same length. The displaced extra-articular vertical neck fracture is routinely amenable to closed reduction by applying dorsal-to-plantar pressure on the head of the talus associated with longitudinal traction and plantarflexion of the forefoot. Direct visualization of the anterior two thirds of the joint is typically available and may be enhanced with use of a distractor (or external fixator). Accordingly, the surgeon should aim for weight bearing as soon as possible after surgery. The femoral component is applied to the condyle and impacted with the punch held at 30 degrees to the long axis of the femur. Gradually, there is limited ability to move the hip joint as inflammation and pressure of the hip joint increase. The frame is reapplied, maintaining the same distance between the clamps and the skin as measured before the corticotomy. Treatment of multiple hereditary osteochondromas of the forearm in children: a study of surgical procedures. Correction of sagittal plane spinal deformities with unit rod instrumentation in children with cerebral palsy. The radiographs allow for classification of the defect and aid in planning for the reconstruction. From a functional perspective, the quadriceps muscle group is actually two groups, the first consisting of the rectus femoris muscle and the second consisting of the triceps femoris muscles (remaining three muscles). Reflex sympathetic dystrophy or complex regional pain syndrome is a chronic pain syndrome that can develop after these ankle injuries. White blood cell count is rarely abnormal in chronic infection and is not helpful for diagnosing deep infection. Chapter 33 Repair of Congenital Pseudarthrosis of the Tibia With the Williams Rod Perry L. After the patient is positioned, prepared, and properly draped and the anatomic landmarks are identified, a 3- to 5cm incision is carried over the capitellum. If unsuccessful, the clavicle can be grasped and pulled upward, especially in thin patients. The gluteus minimus is sharply dissected from the underlying capsule and is retracted anteriorly. Besides the L5 root, the tissue anterior to the sacral ala is retroperitoneal fat. Patients with articulating antibiotic spacers that have a stable press fit, with good rotational stability, are allowed to mobilize touch to light partial weight bearing for 6 weeks, followed by 50% weight bearing for 4 to 6 weeks. The dorsal skin flap measures approximately two thirds the length of the proximal phalanx, and the zigzag incisions are fashioned between the midlines of the syndactylized digits. Patients with more frequent lengthenings have fewer implant problems but more wound problems, whereas patients with less frequent lengthenings have more implant problems and fewer wound complications. The blade is pushed into the intercondylar notch close to the lateral margin of the medial femoral condyle. Low-grade isthmic spondylolisthesis rarely progresses and can be followed with serial radiographs at 6-month intervals until the patient is skeletally mature.

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Cases of recurrence of triggering after surgical release have been attributed to incomplete release symptoms meningitis purchase neurontin american express. Upon completion medicine venlafaxine purchase genuine neurontin on line, the pins can be bent and cut approximately 1 to 2 cm off the skin. The severity of symptoms depends on the virulence of the organism, the overall health or comorbidities of the patient, and the status of the implants and surrounding soft tissues. By using different degrees of cephalad angulation, different parts of the posterior facet may be imaged. Subperiosteal dissection is carried out around the tibia distally to the level of the physis. The depth of the osteochondroplasty ranges from 5 to 10 mm, depending on the severity of the deformity. Implant Placement Perform trial reduction after placing the trial sleeve and femoral stem to assess version, range of motion, and laxity. The option for rotational disparity between the tibial tray and the cone is available in some systems. These regimens reduce both pain and narcotic requirements, thereby reducing perioperative nausea, emesis, sedation, and confusion, and enabling more rapid rehabilitation. This necessitates placing the broach at the level determined by preoperative planning and intraoperative assessment. The lateral margins of these vertebral bodies are removed, including the transverse process and posterolateral bone. The radiographs are assessed and it is determined whether the defect can be reconstructed with a cementless acetabular component or will require an antiprotrusio cage. The thickness of the bearing should be such as to restore the ligaments to their natural tension so that when a valgus force is applied to the knee, the artificial joint surfaces distract a millimeter or two. Distal femoral extension osteotomy without patellar advancement has a high risk of recurrence of contracture and typically results in only partial improvement in crouch. The outer table of the ilium can be exposed either by splitting the iliac apophysis or by dissecting just below the apophysis, in which case the apophysis is then taken off as an entire piece to minimize injury to this growth area. After the hinged brace is removed, patients are sent to physical therapy, where range-of-motion and strengthening exercises are performed. Quadriceps snip is used most commonly, followed by tibial tubercle osteotomy or V-Y quadriceps turndown. Untreated, the natural history of this syndrome involves a residual sensory deficit in the first dorsal web space and contracture of the extensor hallucis longus and extensor digitorum brevis. Each point is acquired by holding the tip of the pointer to the surface of the skin at the required location. If the fibula is an impediment to correction (it usually is not) an oblique osteotomy of the fibula is made and if necessary fixed with a plate and screws. During growth the affected ulna typically remains relatively shortened and curved, and this often leads to significant bowing of the radius. This is the most important aspect of the procedure to mobilize the spine for correction and to achieve a solid arthrodesis. Once further distraction is no longer achievable, final correction and arthrodesis are performed. Distraction gap, percent of femur lengthened, external fixation time index, degree of preservation of knee motion, result score, and complications were compared among the groups. Positioning the patient is placed in the supine position on a radiolucent operating table with a bolster placed under the ipsilateral hip. Cylinder cast with 50 degrees of knee flexion and 45 degrees of hip flexion for walking spica cast. Prepare the metaphysis with the conical reamers that correspond with the last straight reamer. Chronic infections generally present in a delayed manner, usually months or occasionally years after the index procedure. Treatment options are symptom based and can include activity modification, walking aids, nonsteroidal pain medications, and bracing.

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In cases with large anterior osteophytes or preoperative acetabular retroversion treatment 4 autism buy 400 mg neurontin with amex, as noted by a positive crossover sign 6 medications that deplete your nutrients cheap 400 mg neurontin with mastercard, the posterior wall and the transverse acetabular ligament are used preferentially to guage proper anteversion. The surgeon should avoid repair into a medial patella osteochondral fracture fragment; the fragment should be excised first. Additional concerns are bilateral extremity fractures and fractures at different stages of healing. If skin graft is taken from the inguinal region, care should be taken to avoid transfer of hairbearing skin. The subcuticular closure is performed in layers, and a cast is placed with the foot in neutral or slight dorsiflexion. A 15-year-old boy with a displaced tibial tuberosity fracture that enters the joint surface. The entire limb is included on the image so angular deformity can be measured as well as length. Skeletally mature patients may benefit from a procedure that moves the tibial tubercle more anterior (Fulkerson osteotomy). A well-positioned talar dome may be useful as a template to reduce articular fragments. Osteochondral injury in ankle fractures can ultimately lead to symptomatic posttraumatic osteoarthritis, and studies have demonstrated that anatomic reduction is important to prevent this complication. Proximal bone deficiencies around the lesser trochanter can be so profound that a fluted stem is not suitable for femoral revision and a fully porous coated stem for diaphyseal fixation is preferable. The cast is changed under anesthesia in 6 weeks and the hip is examined fluoroscopically. In extreme cases with osteochondral damage, osteochondral allografting can be attempted. The femoral side is observed for lateral asphericity (ie, pistol grip deformity), coxa vara or valga, and osteophytes. The vessel continues toward the posterior spinal musculature arising between the transverse processes during the surgical approach where it is prone to bleed. External Fixator Application the external fixator can be assembled before the procedure begins or just before application. When passing the nails, it is often helpful to pass them both to the level of the fracture and sequentially crossing the fracture site. Treatment of stiff-knee gait in cerebral palsy; a comparison of distal rectus femoris transfer versus proximal rectus release. The tendinous insertion of the gluteus maximus also is repaired, and the fascia lata, subcutaneous fat, and skin are closed. Although clinical symptoms may wax and wane, they generally become more severe, more frequent, and more debilitating over time. This may be further compromised because of the presence of hip flexion contractures. In cases of pathologic fractures through bone cysts, throwing a ball or reaching overhead can precipitate an injury. A concurrent ligamentous reconstruction should not be performed because of postoperative stiffness of the knee joint. Positioning A radiolucent table is used in case an intraoperative radiograph will be obtained. The soft tissue guide is inserted into another clamp position on the same telescoping arm. Intraoperative obturator oblique pelvic radiograph shows the Steinmann pins holding the graft in place and stopping short of the triradiate cartilage. Any extruding cement should be removed with a curette, continuing until the bone cement becomes solid. Any fluid obtained is sent to the laboratory for cell count, Gram stain, and cultures. The ascending branch of the lateral femoral circumflex artery and the accompanying veins run deep to the muscles and must be ligated.