18 year old adolescent footballer with Ankle pain

He has pain on dorsiflexion anteriorly  and posteriorly on plantar flexion both of which are grossly limited

options please

I am planning on both anterior and posterior scopy of ankle, removal of loose bodies and osteophytes and viscosupplimentation.  Cannot expect complete relief in view in joint space narrowing

 Post op pics today

foot and ankle problems and solutions

http://www.ankleplatform.com/.  Check this website by dr. Van Dijk. He has done a lot to popularise current methods of management of foot and ankle problems. Would recommend his course to any upcoming foot and ankle surgeon as well as general orthopod

Type 3 periprosthetic fracture Lt hip

 Patient a 78 year old hypertensive underwent bipolar 8 months back elsewhere and refered to my friend for mangement with a periprosthetic fracture after a fall. There is a doubt about peri-operative infection

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Problems ansd solutions/ 
1. ? infection- Hip aspiration being done for cultures as well as leukocyte esterase test( ref Parvizi guidelines in aaos). if we get the bug even if infected would do one stage with local antiobiotic delivery of choice with HA granules or Calcium phosphate granules both of which are commercially available. 2 stage may be too much for a 78 year old.


2. Widening distal canal compromising regular cylindrical distal fixing stems unless stems locking stems like REEF or aescalup are use. I understand there is an local long stem unipolar with locking available but is a stem with no coating and is a long stem austin moore  for those who want to use it. I do not have faith in these stems.
Solutions.

Modified wagner osteotomy( Anterior) ref pic Above makes quicker sand easier operation. In this case i would prefer it to ETO. Cement and uncemented stem distally and use a bipolar head. The osteotomy helps to cement distally easily as well as remove the stem without further collateral damage. Remove the distal porocoat with a carbide burr to have better cement bone fixtion  as compared to cement implant and  hope fully avoid early loosening. ( my longest follow up for simialar case is 5 .3 years in a n 80 year old- will put it up if I can find it in my blog). If successful we could mobilise him FWB day 1 postop

3. if a high demand patient one would need to use an uncemented long HA of grit blasted stem like REEF or Aescalup stem the name of which i have forgotten

Good luck
jake

Comments by the surgeon

Hip aspiration didnot yield anything yesterday. No frank pus seen. Frozen- 10-12 neutophills. tried to dislocate first but invain. did wagner osteotomy. put in HAP granules into the distal fragment down the canal , after centrifuging it in arthrex machine with polymixin B and vancomycin . Took off the distal coating with burr. 1.2  teicoplanin was mixed with 60 gm.Unfortunately put in the cement a bit early before doughy stage  . Hence was a bit difficult to put it in.

Abt 8cm cement mantle seen in the distal fragment  from the fracture site.

Hap with antibiotics packed in at osteotomy sites and gaps proximally

I would  go PWB to FWB  as comfortable as the cement mantle is at least 8 cm  and what prevents will the pain at the fracture site.

scaphoid nonunion

35 year old rt handed office assistant fell down 3 months back. He was advised surgery by the attending orthopod but refused.  returned 3 months later with the following xray

It was planned for a percutaneous grafting and herbert screw as described the late Dr. Slade. Unfortunately the graft introducer was bigger than the proximal drill hole. The plan was to put the percutaneous wire proximal to distal Drill(red line) the proximal fragment with a larger drill (green line)to put a custom currette thru the hole and currette the cyst and bone graft the cyst with  cancellous grafts thru the custom graft introducer similar to a bone marrow aspiration needle and compress the the fracure with a herbert screw. Finally only percutaneous compression with a herbert screw was done and at 4 weeks the fracture appears to be joining.   Ideally the deformity should be corrected and graft should be used. Luckily this is uniting

TKR iwith a bowed femur

 78 year old lady  with pain in rt thigh and knee. On Investigation her Vit D levels were low, Bonescan picked up the stress fracture. After 3 months of Vit D and PTH a tkr was planned

The limb axis films showed a 12 degree femoral bow.

Options
1. Navigated TKR
2. Custom jigs

3.What  are the options if both are not available

we did a lateral entry with the standard 5 degree femoral jig with a short rod to get the 12 degree cut.
 Navigation or custom jigs are the other options
below is the post op xray. Unfortunately the full length xrays are not availble will update it when she comes next time.

posterior ankle pain- painful os trigonum

Patient presents with posterior ankle pain. Sharp Plantar flexion and external rotation causes pain . Xray confirms a large fused os trigonum and MRI shows the associated inflammation

 A local injection can be used to confirm the same.
traetment involves  hindfoot scopy and excision of both the synovitis and os trigonum