Does length matter- ie: tunnel length of femoral tunnel in acl reconstruction

 

Bone grows circumferentially. There is no evidence that the bone grows from the depth of the tunnel.   I for one use 1 to 1.5 cm femoral tunnels as a quadruple semitendinosis  graft is usually between 7.5 to 8 cm.  Not had a  known case of failure yet due to lack of ingrowth. The gracilis being intact provides an intact agonist for ACL and might help avoid the dysaesthesia from the infrapatellar branch of saphenous nerve. The density in the tunnels in the longer tibial and shorter femoral looks is ISODENSE.

 



THR IN DDH

 The gluteal incision on for hardinge approach is angled inferior than superiorly.  Neck osteotomy and circumferential capsular release and iliopsoas tenotomy is performed. After reaching the psuedo acetabulum the floor of the psuedoacetabulum is cleared and the Holman I a walked on the floor in an inferior direction till the tear drop is reached thereby identifying the true floor. The anterior wall is generally thin. A medial cotyloid fossa is broken or reamed with a 36 reamer to break the medial wall. The further enlargement of the acetabulum is done gradually with a small posterior vector to avoid removing what's remaining  of the matter wall. The uncemented cup which best fits anterior and posterior dimensions and not superioroinferior  dimensions is chosen and fixed with 2 screws. Usually 44 to 46  size cup is used.

PREOP PLANS

POSTOP

THE  SUBTROC SHORTENING OSTEOTOMY  REDUCED A  7 CM SHORTENING TO 3 CM AND THE EXCISED SHAFT WAS SPLIT LONGITIDINALLY TO LIE AS VASCULARISED GRAFT AT THE OSTEOTOMY SITE.

 A SIMMILAR BILATERAL EXAMPLE

 
Another example were the uncovered cup was covered with dowel shaped cancellous grafts impacted into the defect on the left and a flying buttress graft fixed with screws on the right.. the screws on the graft could have been more oblique

ith

periprosthetic fracture post tkr

Th e problems  here are

 1. Osteoporotic bone 2. Short distal  fragment 3. Inappropriate  plate

 My options

 Would include a supra condylar plate augmented with  locking plate.below is a comparable bilateral case in an 89 year old.  The displacement  in the  coronal and saggital axis can be easily controlled by the intra medullary devise and augmented by the locking plate done by a mis technique.

24 year old patient post Gillian barre syndrome with bil hip ankylosis

He was  for 4 months following which was found to have an ankylosis  of both hips. recovered neurologically . He was brougth to us for help in mobilising. he had all  his hip muscle are ossified .  CT angio was done to locate  the vessel and revealed the  the neurovascular bundle displaced anteriomediallly  surrounded by HO.- case done in 2003

Plan. 

Largest bearing possible to avoid dislocation .

Any other suggestions

The hip was approached thru a lateral incision and hip joint accessed from both anteriolateral and posteriolateral. neck osteotomised and the largest MOM bearing(xl head) was used with a sleeve for taper correction for the  xl metal head. there was severe oozing from the raw bone surface which was thought to be controlled with bone wax.

2nd postop day he developed compartment syndrome  of the thigh from the ooze and had to be decompressed.

 

in view of this at three months when the second hip was replaced we used laser to cauterize the bleeding bone which prevented another  compartment syndrome.

3 month later the second hip was replaced  and was mobilized on a zimmer frame and then crutches.

xrays at one year showed some HO formation inspite of preop radiation. at this stage he was still walking with a single stick

 

He returned at 2 years with the pain and the xrays showed  this massive cyst with disappearing bone- the dreaded psuedotumour assocoiated wih this particular implant. This entitiy as not described then and we presented the histology of  Metallosis and ALVAL

 

Sadly the patient ended with bilateral girdlestone as they lost trust in hip arthroplasty