posterior capsulotomy in FFD correction in TKR

Is Posteriors capsulotomy for  FFD correction in total knee replacement ever needed.  Although literature supports such a technique, I feel it's never  needed  and would cause posterior subluxation of the  TKR. The only time i did it early in my career the pt had posterior subluxation. I start with posterior capsule release from tibia later from femur and lastly gastroc origin to correct the bounce if needed. if pt has a tight fixed flexion varus  deformity I would take 2 mm more from the femur to increase the extension gap and use a larger femur in an anterior referencing system if in between sizes to decrease the flexion gap.

 Any other views or comments are welcome.

Anterior column deficiency caused by a loose acetabular cup

 The above  images were sent to me for advise

Comments

There Is superiomedial  migration of the cup compromising the anterior column. The posterior column and wall appears  ok.  One could consider trabecular  metal wedges graft and a cup construct in younger patients as there is no dissociation and posterior column and cup is intact. This patient is 80 years old hence I would prefer a birsch schnider cage  and a cemented cup.  I would bent the inferior flange of the cage to act as hook on the tear drop and fix dome screws first to stabilise  the cage before the superior flange is fixed. The cemented cup can be cemented independent of the  cage in correct inclination and anteversion. A bit of. cement uncovering is aceptable.

Mesenchymal stem cells in cartilage injuries

The buzz in cartilage  injuries today rests on mesenchymal stem cells from bone marrow. adipose tissue, synovium and even the omnipresent  pericytes. The techniques in harvesting and delivering it to the chondral defects are more or less evolved. The arguments with regards to the no of cells when harvested   and directly implanted or  should be expanded needs to be answered. The cellular cross talk in local environemnt appears to guide the chondroblast formation. The pioneers AA Shetty(UK) and Kim(Korea), A Gobi  from bologna university and japan are way ahead the rest of us. I believe there is finally light at the end of the tunnel with regards to stem cells in cartilage injury.

As far as micro fracture is concerned, the use of the chondral pic is obsolete. As the pick jams the subchondral bone into the hole preventing the MSC cells from escaping the bone marrow. therefore a 2 mm drill would be ideal and a depth of 4mm is advisable. The problems of subchondral  hypertrophy in both microfracture and chondrocyte implantation is real. The management of these are still evolving