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

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

Painful left wrist in a rt handed doctor

 

From the above  xrays  the patient has  a grade 3A Litchman lunatomalacia. 

AP shows a flexed scaphoid ( ring sign) with the carpal ratio altered suggesting lunate foreshortening. 

Radial styloid appears sharp - radial styloid  OA. 

clenched fist AP ( Why)does not show a flexed scaphoid.( cannot explain). is it a correctable scaphoid flexion

Definite ulnar minus

 What would you do?

1. joint levelling procedure ie; radail shortening

2. radial styloidectomy and Scapholunate fusion to unload the lunate with or without lunate excision

3. STT fusion

4. revascularisation  with interacarpal vessel

 my suggestion would be to scope to see if radioscaphoid (styloid OA is present) if present my choice would be no 2. if not 1.

 Any valid advise is welcome for the friend who asked for my opinion

Dislocated bipolar in an octegenarian household ambulator

The decision to do a bipolar is probably correct. the postoperative dislocation and repeated instabilty was surprising. May be a touch of decrease offset added to the instability. If these were a tripolar cup one could imagine an impingement between the neck and the large polyhead could contribute to instability.

intraop the patient had global instabilty due to possible  wrong stem versiosn and soft tissue laxity. we revised the stem with a cememt on cement smaller stem causing smaller offset and still having laxity. so intraop we decided to go for a constrained liner as she was low demand.  

The  final post op xrays with a the +3 head and constrained liner stabilised the hip. The cup is a touch too medial which could have been avoided.  the other option would have been a tripolar cup which could dislocate too due to impingement. The constrined liner could dissociate at the stem head junction if tested as well as wear more quickly

Oops! post acl recon

The patient feels that his knee is not right. He has a 3 degree ffd, full flexion

Femoral component loosening in a ha coated stem in one year

The questions asked were whether revise only the stem and secondly uncemented or cemented revision

My opinion is as follows

The femoral stem has major osteolysis,new bone formation, short duration of implantation and had problems during primary as seen by the circumferential ss wires. It is infected unless proved otherwise. One should aspirated, le test, and intraop frozen section. If you got a decent bug preop one could consider a one stage revision, otherwise be safe and do a 2 stage revision. My choice of stem will be srom and would revise both cup and stem if infected and would go for stem only if the lab is trusted and negative. You could use any modular or mono lock distal loading stem too.

revision

Patella in femur

This xray shown to me by ny colleague is again a pattern I have never seen before. the quads was torn and the distally rotated patella was foung inside the intercondylar fractured femur.

Is this divergent hip dislocation

This radiograph was shared with me  by a colleague. Rt anterior dislocation and Lt posterior fracture dislocation in an RTA.  I have never seen this kind of an  injury before. Apparently he was thrown  off a  moving vehicle and succumbed to his

injuries before orthopaedic intervention..  The direction and magnitude of force  and position of limb at the point of impact determines the injury. The dash board injury and the boat injury combined as described historically

4 yr old painful bipolar arthroplasty in a financially challenged patient referred for opinion

Problems. 

Need a lateral X-ray of the distal stem to see the curvature as well quantify the erosion

I Do not have the patients age 

Financially  challenged patient

Loose stem and possibly cement mantle

Distal long cement mantle

 Medial cortical erosion at the distal end of site

?. Acetabular superior erosion

Hopefully no infection- to be ruled out by preop markers, LE  test and intraop frozen sections and cultures

 A THR is the only option. The  cost of the stem may be the compromise.  I would not use a cemented stem unless you can roughen the smooth endosteal surface abraded by the cyclical stem movement with a broach or burr for cement macro lock (difficult) or if one is good at impaction grafting and a cemented stem ( demanding in technique and patience).

Solutions

 Easy explant with proximal cement mantle and insert a tight fitting HA coated stem like corail after broaching complete removal of proximal cement mantle only and the stem should stop short at least 2 cm above the medial cortical defect - the problem of a peri prosthetic fracture  is real. 

Will a lateral by passing plate to protect the erosion with proximal wires and distal screws help in the compromise. One needd to wait and see. Would local bisphonates  or osteblasts help?

 There used to be a short grit blasted cone  stem by Wagner   With which I had revised in 2002. Iunderstand that zimmer takeover  of Sulzer orthopaedics  killed it.

 Ideally you need a long proximal loading distal fitting stem if the distal cement mantle can be removed  without an eto.  If not an ETO, take the distal cement mantle  and one should get 6 mm of distal scratch fit with a  poor coat stem like solution or even echelon. Template first please

supracondylar nonunion in 62 year old RA patient

This case was  refered for opinion by a colleague from india. Any advise is welcome.

 

My suggestion would be to go for cemented Rotating hinge with distal femoral reaplacement if the nonunion is confirmed intraop. In case there is evidence of  significant stable union I would consider a stemmed,sleeved varus valgus contrained knee aiming for 10 to 15 year survival