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The American Academy of Orthopaedic Surgeons
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Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy’s Annual Meeting, will be available in February 2012 in Instructional Course Lectures, Volume 61. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8A.M.-5P.M., Central time).
Surgical Techniques for Complex
Proximal Tibial Fractures
Jason A. Lowe, MD, Nirmal Tejwani, MD, Brad Yoo, MD, and Philip Wolinsky, MD An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
Traditional and Alternative Surgical Approaches to the Tibial Plateau: How to Select Them?
Any surgical approach for fracture fix-ation should facilitate visualizfix-ation of fracture fragments and allow the appli-cation of optimal fixation devices and soft-tissue repair. Treatment goals ap-plied to tibial plateau fractures include anatomic articular surface reduction, restoration of the anatomic axis, and preservation of the menisci. The ap-proach should not devitalize soft tissues or cause further injury to surrounding structures. An ideal surgical dissection encompasses these principles and per-mits early joint motion.
The midline longitudinal incision is the favored approach to the knee joint, as this incision facilitates knee replace-ment if needed in the future. Surgical exposure for complex injuries (bicon-dylar fractures) requiring dual fixation needs large medial and lateral flaps that add to soft-tissue complications. Other surgical approaches allowing a more direct approach to the fracture to de-crease the risk of soft-tissue injury from
excessive retraction or periosteal strip-ping are available. When one incision does not adequately expose the fracture, it is better to use a dual incision than a single midline exposure1-3
. Anterolateral Approach
The anterolateral approach is used for the most commonly seen tibial plateau fractures (Schatzker4
types I, II, and III). It is also used for the lateral part of a dual incision approach needed for internal fixation of a bicolumnar frac-ture. The incision is centered on Gerdy’s tubercle and is shaped as a lazy S or a hockey stick. The fascia is elevated off the tibial tubercle to expose the lateral tibial plateau. The knee capsule is incised, and a submeniscal arthrotomy allows visualization of the articular surface (Figs. 1 and 2). In addition to visualization of the articular surface, this approach allows repair of any meniscal tears.
Medial Approach
The medial approach is used for a medial tibial plateau fracture (Schatzker
type IV) or as part of a dual approach to the plateau. The incision parallels the posteromedial border of the proximal part of the tibia. The pes anserinus is elevated, the fracture reduced, and fixation implants are placed beneath the pes anserinus. The pes anserinus may either be retracted (Fig. 3) or incised, with repair after fracture fixa-tion. The medial meniscus cannot be elevated as is possible with the lateral meniscus; therefore, the limitation of this approach is the limited visualiza-tion of the articular surface of the medial plateau. Also, access to the pos-terior plateau is limited, but the medial approach can be converted to a postero-medial approach.
Anterior Approach with Tibial Tubercle Osteotomy
The advantage of the anterior approach with osteotomy of the tibial tubercle is that the tibial plateau and the intercon-dylar notch are completely exposed, allowing reattachment or primary su-ture of the cruciate ligaments5
. This approach is rarely used, and most
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
complex, bicondylar fractures are now treated with use of dual incisions. Posteromedial Approach
Medial tibial plateau fractures extend-ing to the posterior aspect of the tibial plateau, posterior metaphyseal frac-tures, or those that require a buttress on the posteromedial cortex are best fixed with use of the posteromedial approach. Fragment-specific fixation of the medial plateau is recommended over stabilization with a laterally based locking construct6
. To obtain optimal
fixation of bicondylar fractures, a dual plating technique is recommended, with one plate fixing the medial frag-ment and one fixing the lateral plateau. Medial plateau fractures may be me-dial or posteromeme-dial, with each re-quiring a plate to be, ideally, placed at the apex of the fracture (fragment-specific).
The patient can be positioned prone or supine7
. An incision is made over the posteromedial aspect of the knee (Fig. 4). Dissection between the medial head of the gastrocnemius
mus-cle and the semitendinosus musmus-cle allows exposure of the semimembra-nosus muscle, which is detached for better access to the posterior aspect of the tibia. Visualization of the articular surface is limited, but, if necessary, visualization can be improved with a longitudinal split in the medial collat-eral ligament and capsule. Through this incision, visualization of the articular cartilage can aid in congruent joint reduction.
Posterior Approach
An isolated posterior shear fracture, a posterior cruciate ligament avulsion fracture with a large osseous fragment, or a posterior fracture dislocation is best exposed with a posterior approach8,9
. A z-shaped incision across the flexor crease is used. The deep tissue planes are between the medial head of the gas-trocnemius and the semimembranosus muscles or between the two heads of the gastrocnemius muscle with protection of the neurovascular structures. The medial or lateral head of the gastrocne-mius muscle may be partially detached, if it is necessary to improve exposure, enable fracture reduction, or insert fixation on the posterior rim. Extended Lateral Approach with Fibular Osteotomy
The Lobenhoffer approach is used to expose fractures of the lateral tibial plateau that extend posteriorly when the head of the fibula limits the exposure10,11
. The skin incision is made along the course of the peroneal nerve, pos-terior to the fibular head. After dissec-tion, the common peroneal nerve is protected and an osteotomy of the fibula at the junction of the head and neck is performed, leaving the proximal at-tachments intact. This allows exposure of the tibial plateau from anterior to posterior.
Another way to approach the posterolateral plateau is without a fibu-lar osteotomy10
. Absence of an osteot-omy makes it more difficult to visualize the tibial fracture at the level of the fibular head; however, this approach is preferred as it avoids the risk of a nonunion at the fibular osteotomy site. Fig. 1
Clinical photograph of a patient’s right knee with the lazy-S incision used for internal fixation of a lateral proximal tibial fracture.
Fig. 2
Clinical photograph of a patient’s right knee with retention sutures in the lateral meniscus (white arrow) of a submeniscal arthrotomy.
Medial Tibial Plateau Reduction A shearing force produces a coronal plane fracture comprising approxi-mately 25% of the medial articular surface12
. This fragment is seen on a lateral radiograph, but the full extent of articular involvement is best appreci-ated on sagittal computed tomography (CT) images. Since the medial
collat-eral ligament (MCL) prevents a sub-meniscal arthrotomy, reduction of the medial joint line is often obtained indirectly with anatomic restoration of the medial cortex. If there is a question about the accuracy of the reduction of the articular surface of the medial plateau, a longitudinal incision is made in the MCL, where the fracture enters
the medial aspect of the joint. Ana-tomic reduction is confirmed by aligning the articular cartilage of each fragment while the cortex is reduced with a well-placed Weber clamp per-pendicular to the fracture. This white-white read of the medial plateau articular cartilage augments accuracy of reduction.
Medial Plateau Fixation
Surgical stabilization of isolated me-dial plateau fractures (Schatzker type IV) is accomplished with an under-contoured, nonlocking, flexible plate (1/3 T-plate or reconstruction plate) applied as a buttress. Fixation of the medial plateau in Schatzker type-V and VI fractures is more controversial. Stabilization can be accomplished with locking screws placed through a later-ally based implant alone or stabilized with a medial plate as part of a dual plating construct (medial and lateral plate)13-17
. Biomechanical and clinical data support both techniques. Al-though lateral-only locked plates re-duce surgical time, blood loss, and limit soft-tissue stripping, a high rate of articular subsistence (26%) has been reported13-17
. Displacement of the me-dial fragment can result in knee in-stability, pain, and posttraumatic osteoarthritis12
. The authors, there-fore, recommend fragment-specific fixation of the posteromedial and lat-eral plateau through a two-incision approach for bicondylar tibial plateau fractures. Fragment-specific fixation of the medial plateau avoids inadequate purchase of the posteromedial frag-ment observed with lateral-only lock-ing screws6,16-18
. The benefit of added fracture stability is offset by greater surgical time and higher postoperative infection rates. Current reports have demonstrated postoperative infection rates of 8.4% with dual plating com-pared with 1.6% with lateral-only fixation13,14
. In the absence of a pro-spective, randomized, controlled trial comparing these surgical approaches, the need for anatomic reduction of the joint surface and adequate stabiliza-tion of the medial plateau takes precedence.
Fig. 3
Clinical photograph of a patient’s left knee with a medial incision (patient’s head is to the left). The tendons of the pes anserinus (white arrow) are seen over the clamp.
Fig. 4
Clinical photograph of a patient’s right knee. With the patient in the prone position, the solid line identifies the level of the knee joint with the femur to the left. The dashed line illustrates an incision for a posterior-medial incision.
Lateral Plateau Articular Reduction High-energy bicondylar tibial fractures are typically associated with articular surface impaction of the lateral plateau. Successful restoration of the lateral aspect of the joint requires adequate visualization and an array of reduction techniques. A submeniscal arthrotomy and a laterally based femoral distractor improve visualization of the articular surface when needed. A single Schanz pin is placed into the femoral meta-physis, parallel to the joint line, and a second Schanz pin is placed in the tibia, distal to planned plate placement lo-cation19
. Care must be used with placement of a lateral tibial pin so as to not injure the neurovascular struc-tures of the anterior compartment20
. Applying distraction opens the joint and enhances visualization of the lat-eral plateau. Retraction of the postero-lateral or anteropostero-lateral fragments (opening the door) can allow even more visualization.
Mobile articular pieces are re-duced with a dental pick or a small (0.45 to 0.62-mm) wire and are temporarily stabilized with Kirschner wires. Im-pacted articular fragments must be mobilized from surrounding cancellous bone before they can be reduced. A 1/4
to 1/2 in (0.64 to 1.3-cm) osteotome or bone tamp is used to elevate 1.0 to 1.5 cm of cancellous bone with the ar-ticular segment. Once levered into po-sition, the fragment is stabilized with Kirschner wires. With the impacted segment reduced and secured with wire fixation, bone voids can be filled with graft material and the lateral segment can be reduced (closing the door). The medial and lateral plateaus can be re-duced and compressed with a periartic-ular reduction clamp19
.
The contained defect of a pure depression fracture cannot be reduced without an osteotomy. If there is an incomplete fracture, the articular seg-ment is accessed by completing the fracture and reducing the articular fragment as described above. If there is no cortical fracture, articular reduction is done with one of two techniques. The Fig. 5
Clinical intraoperative photograph of a patient’s left knee, demonstrating incisions for minimally invasive plate osteosynthesis.
Fig. 6
Anteroposterior radiograph of a knee illustrating the inability of locking screws to reduce the valgus malalign-ment in the coronal plane. As a result, a valgus malunion, with the plate poorly apposed to the tibia, is observed.
Fig. 7
Fig. 8
Fig. 7 Anteroposterior and lateral radiographs of an extra-articular proximal tibial fracture demon-strating the most common defor-mities (valgus and procurvatum) observed in these fractures. Fig. 8 Anteroposterior radiographs showing how a medial starting site produces a valgus deformity as the intramedullary device en-ters the tibial diaphysis.
anterior compartment is released from the metaphyseal flare for both. One technique is to use the DHS (Dynamic Hip Screw; Synthes, Paoli, Pennsylvania) set and fluoroscopic visualization. The guidewire is directed from the lateral tibial metaphysis toward the impacted segment. The cortex is then opened with the cannulated 11-mm reamer from the DHS system. Bone tamps are introduced and used to tap the articular segment into place. The articular reduction is confirmed by direct visualization through the submeniscal arthrotomy. Alternatively, a lateral osteotomy is made with drill holes (2.0-mm drill-bit) in a diamond pattern, with the drill holes connected with use of a 0.25-in (0.64-cm) osteotome. The articular segment is reduced as just described. With either technique, the articular fragments can be supported with Kirschner wires and bone graft prior to definitive fixation.
Lateral Plateau Fixation
Surgical stabilization of the lateral plateau must maintain reduction and rigid fixation of the articular segment to a well-aligned tibial shaft. The joint surface is stabilized with multiple parallel screws placed just beneath the subchondral bone. These rafting screws support the reduced articular surface fragments and can be the prox-imal screws of a 3.5-mm or a 4.5-mm, precontoured periarticular plate or with minifragment (2.4 or 2.7-mm) screws. Minifragment screws and plates are favored for articular comminution with fragments having minimal sub-chondral bone or when the proximal screws in the precontoured plate are not subchondral.
The articular segment is reduced to the shaft with traction (a manual or femoral distractor). First, the plate is fixed to the proximal segment with bicortical screws (locked or nonlocked) inserted parallel to the joint21
. The plate is reduced to the tibial shaft with a bicortical screw or a so-called whirlybird push-pull type of device. It is important to ensure that this does not malreduce the fracture in the coronal plane, and locking screws should not be placed in
the distal segment until the alignment is correct22
.
Minimally Invasive Plate Osteosynthesis
The proximal tibial anatomy and fracture pattern must be clearly understood if precontoured plates are used with mini-mally invasive techniques. The articular surface is visualized with a small arthrot-omy, and percutaneous techniques are used for screw placement into the tibial shaft (Fig. 5). One must be careful when this technique is used for plates longer than eleven holes, as the neurovascular bundles in the anterior and lateral com-partments are at risk12,23
. Locking Screws
Locking screws increase construct ri-gidity, but they should be placed bicortically21,24
. They are useful in se-verely osteoporotic bone, substantial metaphyseal-diaphyseal comminution,
or short-segment periarticular and/or intra-articular fractures. Malunion has been a problem, and it is necessary to pay meticulous attention to fracture reduction before placement of locking screws (Fig. 6)25
.
Intramedullary Nailing of Proximal Tibial Fractures
The use of an intramedullary nail for fracture stabilization is appealing. The insertion point of an intramedullary nail is remote from the fracture site, mini-mizing vascular disruption of the fracture fragments, the implants are centrally located, and tibial diaphyseal fractures have a high rate of union and low rate of complications. As a result, the use of intramedullary nailing for tibial fractures has expanded from mid-shaft diaphyseal fractures to proximal fractures26-32
. In-tramedullary nail fixation is technically more demanding for proximal tibial fractures than for diaphyseal fractures.
Fig. 9
Lateral radiographs showing how an inferior starting site and posterior nail trajectory produce a procurvatum deformity of the proximal segment as the nail enters the diaphysis.
Fig. 10 Fig. 11
Fig. 12
Fig. 10 Anteroposterior radiograph demonstrating an appropriate starting site, just medial to the lateral tibial spine and in line with the mechanical axis. Fig. 11 Lateral radiograph demonstrating a correctly selected starting site and wire trajectory. The wire is just anterior to the articular margin and directed parallel to the anterior tibial cortex. Fig. 12 Anteroposterior and lateral radiographs with a protection sleeve for a retropatellar tibial nail centered at an appropriate starting site.
Unlike intramedullary nailing of a di-aphyseal fracture, placement of the in-tramedullary nail does not reduce a proximal tibial fracture, and malreduc-tions of proximal tibial fractures with intramedullary nail fixation are reported to be as high as 84%27,33-36
.
The typical deformity caused by intramedullary nailing of proximal tibial fractures is valgus and apex anterior angulation with anterior translation of the proximal fragment (Fig. 7). The valgus deformity is due to an imbalance of muscle forces on the proximal frag-ment and is accentuated when the insertion point is too medial or directed laterally. The tip of the nail can abut the lateral cortex causing the proximal fragment to rotate into a valgus position (Fig. 8)34,35,37
. The apex anterior deformity results from a combination of the pull of the patellar tendon34
, a distal insertion site, or a posteriorly directed nail that deflects off the posterior tibial cortex and rotates the proximal fragment (Fig. 9). Nails with an accentuated distal Herzog bend may translate the proximal frag-ment anteriorly, described by Henley et al. as the wedge effect38
. To prevent malalignment of proximal tibial fractures during intra-medullary nailing, one should properly place the starting point; reduce the fracture prior to guidewire placement, reaming, and nail insertion; and hold the reduction until all of the locking bolts have been inserted.
The Proper Starting Point
Fluoroscopic imaging is used to obtain good anteroposterior and lateral C-arm images of the knee. The starting point on the anteroposterior radiograph is in line with the medial border of the lateral tibial spine (Fig. 10). The insertion site on the lateral radiograph is slightly anterior to the anterior margin of the articular surface. The guidewire and nail are inserted as parallel to the anterior cortex as possible (Fig. 11).
Fracture Reduction Techniques
Extended Leg Position
It is critical to reduce the fracture and maintain the reduction during fracture fixation. The intraoperative position of
the leg affects fracture reduction. When the knee is maximally flexed, which facilitates collinear insertion of the nail
with the anterior tibial cortex, the pull of the patellar tendon increases the apex anterior deformity. When this occurs, the Fig. 13
Anteroposterior and lateral radiographs with a proximal Schanz pin for the AO distractor, appropriately placed parallel to the articular surface (left) and posterior to the nail path (right).
Fig. 14
Anteroposterior and lateral radiographs demonstrating an appropriately placed distal Schanz pin inserted parallel to the ankle joint and posterior to the nail path.
apex deformity can be limited by placing the instrumentation in the leg with minimal knee flexion39
. Originally, semi-extended nailing was performed through a large medial parapatellar incision; however, it can now be done with a small suprapatellar incision. The instruments and nail are passed through protective sleeves, posterior to the patella to the proximal part of the tibia (Fig. 12)16
. Recent studies have suggested this tech-nique can be used without injury to the patella or femoral articular cartilage, the menisci, or the anterior cruciate liga-ment16,18,40
. No outcomes data are avail-able for this technique.
Use of a Femoral Distractor or an External Fixation Frame
A universal distractor or an external fixator can be used to obtain and maintain fracture reduction. With use of fluoroscopic imaging, a proximal Schanz pin is inserted from the medial side of the proximal part of the tibia posterior to the planned intramedul-lary nail path (Fig. 13), and a distal Schanz pin is placed medially in the posterior malleolus (behind the nail) or at the level of the physeal scar (Fig. 14). The pins should be inserted parallel to the proximal and distal joint lines. Application of traction through the frame until the pins are parallel typi-cally results in adequate reduction34,41
. Temporary Plate Fixation
A small plate can be used as a temporary reduction device29,42
. The plate may be placed on the medial or lateral tibial border, but the medial border is better since the medial side of the fracture is often less comminuted. The medial incision is positioned posterior to the posterior borders of the tibia so that if the incision fails to heal, no bone will be exposed (Fig. 15). Minimal deep dis-section is needed, and the plate is placed over intact periosteum. Unicortical screws are used so the reamer and nail can pass. After insertion of the nail and all interlocking screws, the plate may be removed or the screws on the proximal side of the fracture may be taken out. The plate then acts as a buttress con-struct, preventing a deformity from
recurring while permitting relative mo-tion at the fracture site.
Blocking Screws
So-called blocking or Poller screws can be used during intramedullary nailing of proximal tibial fractures. They are placed preemptively in an effort to prevent a deformity or as a so-called bailout after deformity has occurred. They are used to narrow the canal, to create a path, or as an artificial cortex for the nail to pass down28,33,43.
Blocking screws are inserted per-pendicular to the plane of the deformity, on the concave side of the deformity, within the more mobile fracture segment. For example, with a valgus deformity, the screw is placed from anterior to posterior, on the lateral side of the instrument path, and in the proximal segment (Fig. 16).
The screw functions as a so-called artifi-cial cortex.
Blocking screws can also be used for an anterior malalignment. The blocking screw is placed slightly poste-rior to the midline, from medial to lateral, in the proximal fragment (Fig. 16). As a nail is inserted, it contacts the blocking screw, extending the proximal fragment and decreasing the apex ante-rior deformity. The screw should not be placed in the midline since nail passage may be blocked by the screw.
Percutaneous Clamps
The orientation of a fracture line may allow percutaneous placement of a reduction clamp to obtain and maintain the reduction (Fig. 17). The use of clamps has not been shown to increase infection rates44
. Fig. 15
Anteroposterior and lateral radiographs with a provisional locking plate on the posteromedial tibial cortex. Unicortical locking screws are used so as to not obstruct insertion of reamers or the intra-medullary implant.
Implant Selection
It is important to know the implants in order to ensure that at least two locking screws can be placed in the proximal segment. The distance from the end of the nail to the locking bolts determines how far proximal or distal fracture lines can extend and still be stabilized by the intramedullary nail. The number and orientation of the proximal and distal interlocking bolts vary by implant. Oblique bolts have demonstrated more stability than transverse bolts in resist-ing coronal plane deformity, but not axial or torsional stability38
. The com-bination of oblique and transverse interlocking screws increases construct stability45,46
. Intramedullary devices with a distal Herzog bend may accen-tuate a sagittal plane deformity because, as the Herzog bend contacts the pos-terior cortex, it can create a so-called wedge effect and translate the proximal segment anteriorly (Fig. 18)38
.
Complications and Pitfalls
Knee pain, after intramedullary nailing of the tibia, affects 60% to 70% of patients47-50
. The anterior knee pain is exacerbated by kneeling, squatting, stair climbing, or high-performance athletic activities. Implant removal after fracture union has had inconsistent results with regard to relieving anterior knee pain. There is no difference in the prevalence of knee pain when a transpatellar or parapatellar incision is used.
The prevalence of malunion has been reported to be as high as 84%36
. With use of the techniques described in this article, malunion rates have been reduced to between 8% and 23%28,29,31
. Strict attention to surgical technique and the use of reduction aids decrease the prevalence of malreduction.
Infections and nonunions are most commonly associated with open and/or comminuted fractures29,31,36,42,51
. Ultimate union rates of 91% to 100%
have been reported, but the union rate following primary fixation is approxi-mately 77%28,29,36,42
. Lindvall et al. re-ported a 100% union rate for closed tibial fractures and a 23% rate of non-union for open fractures stabilized with an intramedullary nail31
.
Patient-specific contraindications to the use of an intramedullary nail include open physes, intramedullary canals too narrow to allow insertion of a nail, pre-existing canal deformities, knee contrac-tures, and so-called blocking hardware such as an ipsilateral knee replacement or knee fusion. Fracture-specific contraindi-cations to the use of an intramedullary nail include substantial intra-articular in-volvement, and short extra-articular seg-ments that preclude placement of at least two interlocking screws6
.
Nails Compared with Plates
A literature meta-analysis found a trend toward an increased prevalence of mal-union after intramedullary nailing compared with plate and screw osteo-synthesis (p = 0.06), but a lower infec-tion rate after intramedullary nailing (p < 0.05)52
. Lindvall et al. also demon-strated a trend toward a higher mal-union rate for intramedullary nailing (p = 0.103), a threefold increased rate of hardware removal after plate and screw fixation, and no difference in implant failure between these two techniques31
. Both intramedullary nails and plates can be inserted with use of surgical tech-niques that respect the local soft-tissue biology. These techniques optimize fracture-healing and contribute to a high rate of fracture union for both operative procedures27,29,52,53
.
Implant failure has been reported for both intramedullary nails and plates35,36,53
. Early studies of intramedullary nails had implant failure rates as high as 25%, while only 2.6% of plates failed36,53
. Many early failures of intramedullary nails involved small-diameter locking bolts24
. More recent literature has demonstrated similar prevalences of implant failure for intramedullary nails and plates2,28,31,34,54,55
.
Overview
Extra-articular proximal tibial fractures are technically demanding fractures to treat. Fig. 16
Anteroposterior and lateral radiographs demonstrating proper positioning of blocking screws to aid in fracture reduction and strengthen the implant construct. Anterior-posterior screws placed lateral to the nail (white large arrows) prevent valgus deformation, and medial-lateral screws placed posterior to the nail (white small arrows) prevent procurvatum.
Fixation with an intramedullary nail re-quires a firm understanding of the anat-omy of the proximal part of the tibia, the fracture pattern, the deforming forces, and the implant system. The prevalence of malreduction can be reduced with use of meticulous surgical technique, a correct nail insertion site, and adjuvant reduction aids. The rates of postoperative infection and nonunion are related more to the nature of the injury (open and com-minuted) than to the implant. Patients should be educated on the occurrence of postoperative functional knee pain,
which seems to occur more commonly in younger, more active patients.
Jason A. Lowe, MD
University of Alabama at Birmingham, 510 20th Street South, FOT 960, Birmingham, AL 35294 Nirmal Tejwani, MD
NYU Orthopedic Surgery Associates, 301 East 17th Street, Suite 1403, New York, NY 10003
Brad Yoo, MD Philip Wolinsky, MD
Department of Orthopaedic Surgery, University of California Davis, 4860 Y Street, Suite 1700, Sacramento, CA 95817
Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy’s Annual Meeting, will be available in February 2012 in Instructional Course Lectures, Volume 61. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8A.M.-5P.M., Central time).
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Fig. 17 Fig. 18
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