When do one allow contact sports after ACL reconstruction

 Conventionally one allows contact sports within 6 months post reconstruction . Recent  evidence suggests that it would be prudent to delay contact sports to 12 months post  acl reconstruction with the widely popular hamstring tendons (Am j sports medicine). The reported rates of first year revisions are higher in hamstring group. One could postulate  that it is due to the delayed bone in growth in the tunnels or the  donor hamstrings regeneration time which is a dynamic  acl agonist.

Meniscal root repair simplified

 The  currette is used to freshen the area of root attachment. A suture lasso is introduced from superior to inferior  and a PDs suture is loaded through the the loop. The 2  free ends are threaded through  the  pds loop to get a locking loop which brought out  by a ACL  jig guided wire passer to tie on a button on the proximal tibia.

 Earlier I used to pass two sutures which sometimes tore the ? Degenerate posterior horn while tightening . With the locked loop one can distribute the forces over a larger area without the risk of a tear. The same technique has been used to anchor bony avulsions of acl and pcl.
 recently I  use the knee scorpion

Biocomposite screw is not harmless

 This patient is 2 yrs postop acl recon playing professional club football. Presented eith  2 month pain and swelling anteriomedial tibia. Knee stable and normal. MRI pics below

A waiting cultures including mycobacterium and fungal. All cultures were negative. Inspite of B tcp which was to reduce local infalmmmation by bringing in osteoblasts early. this happened. wouldn't peek implants be better as thet do not xause anty local reaction

supracondylar periprosthetic fractures post tkr. nail plate devise- a new concept

Supracondylar femoral fracture is a devastating complication after a total knee replacement. Supracondylar femoral  fractures account for about  0.3 to 2.5 %.. With rising numbers of knee replacements the number of these fractures are going to rise.  The treatment is technically challenging in type 2 fractures .  In type 1 conservative treatment is acceptable and revision is advised in type 3

The benefits of total knee replacement have been well documented. Periprosthetic fractures involving distal femur, proximal tibia or patella especially during the postoperative period causes considerable morbidity to the patient and is a technical challenge to the treating surgeon.  Majority of these fractures occur after a trivial fall. Rheumatoid patients receiving corticosteroid and immuno suppressant  therapy, severe osteopenia and osteoporosis, old people, women are at a greater risk for supra condylar fractures. Severe osteoporosis makes fracture fixation difficult.  High incidence of supracondylar fractures (40-52%) has been reported with anterior femoral notching.

Both conservative and surgical modalities of treatment have been described in the management of  these fractures. Favourable results have been documented in certain studies  with conservative management . In general,  conservative methods may be utilized in type 1 fractures  ( Lewis and Rorabeck ), provided the patients are followed up with xrays at regular intervals . Displaced supracondylar fractures (type 2) needs to be properly aligned and stabilized for an optimal outcome. Stabilization using intramedullary nails, locking plates, external fixators have been described.   Type 3 fractures may require a revision with distal femoral replacement prosthesis or a structural allograft.  

Proper alignment and stabilization of the fracture is mandatory for early mobilization of the knee. In type 2 frequently the  far cortex is weak or communited, rigidity with a an intramedullary nail  or a locking plate  alone is suboptimal for mobilisation.  In such instances a combination of a nail plate devise  which are interconnected and locked to each other (locked screw on the plate and a locking nut on the screw and nail would increase the rigidity of the construct enabling early mobilisation of the patient. A blue print for such a devise and introducing instrument is given below.

In 2009 following difficulty in stabilising these distal femoral fractures,  combination of a separate  Intra medullary nail  and a locking  plate  was used to stabilise and mobilise the elderly  above mentioned osteoporotic fracture. This was  repeated in  bilateral case where in the nail was removed  to pass the distal locking screws  from the plate resulting in translation of the distal fragment refer   pictures   below.  Both the fractures healed in 3 months with no lag and loss of pre-fracture motion

 

 

 

 
 
 
 
 
 
 
 
 
 

 

 

 

 

 

Technique 

Knee replacement incision. A supracondylar nail 9 mm in diameter was passed through the distal fragment  and using this to reduce the fragment and pass it retrograde into the proximal fragment. This avoids soft tissue stripping and quick reduction of the fracture in anterior-posterior and medial lateral planes  with out soft tissue stripping associated with reduction with a plate device. This nail devise could be locked proximally and distally if possible or at this stage a locking plate is passed through a MIPPO technique on the lateral  femoral side through the same tkr incision and locking screws can be applied distally though the incision and percutaneous screws can be applied proximally. In the case  in picture on the right knee the nail was removed after the plate was applied distally to facilitate  screw insertion resulting in translation in the medio-lateral plane. Therefore it was decided to use both nail and plate in 3 further cases where in we obtained stable reduction to facilitate immediate mobilisation.

 With these results we attempted to design a new implant ( nail plate device) to improve the technique and rigidity of  fixation

jig to implant the nail plate devise

nail plate devise locking both together in cases of communition

 

Ligamentous injury to knee a simplified reproducible method

 I do feel unlike many other joint injuries the mangement of ligamentous injuries in knee is clear cut with studies showing good results with the current techniques. 

ACL  tear. Best diagnostic test is Lachman where in the end point is qualified by being soft or hard. The degree of tibial movement is graded upto 5 mm , 5 to 10 mm and more than 10 mm. If one can elicit a pivot shift it would be more conclusive. MRI should  not be taken as an indication  for surgery as many partial tears are unstable on clinical exam. 
Even a grade 1 with - soft end point would need a surgical intervention within a few weeks to days if there are no geographic bone bruise  and full rom to prevent further meniscal and chondral injury

PCL  tear. The simplest assesment is the step off sign. 
Grade 1.   Tibia still in front but less than normal at 90 degree flexion
Grade 2. At the level of femur
Grade 3. Behind the femur.
One could  always push posterioly further to asses the end point
To complete the assesment of the posterior ligamentous structures
A posterior draw in neutral, int rotation and external rotation  is done. If the posterior draw is exaggerated in internal rotation the posteriomedial corner is incompetent. For posterior lateral the dial test  at 30 degrees is more accurate. The step off sign, posterior draw in internal rotation and dial test  gives an accurate diagnosis of the posterior ligamentous structures of the knee.
 The management is as follows
Grade 1 conservative- essentially intensive quads strengthening along with general measures

Grade 3 always surgical reconstruction.
Grade 2-  is were the controversy exists. My take would be if either poster medial corner or posterior later corner is compromised I would proceed to reconstruct the pcl and the affected corner as soon as the knee is quiet within 2 weeks

 To complete the collaterals can be tested in 30 degrees flexion. The LCL can be palpated in figure  of four  Position like a cord if palpated perpendicular to its direction. 

The LCL is best atreated surgically while the MCL management is more controversial. My general rule on medial side is repair of the tibial side avulsion if lax and conservative on the femoral side generally. The tibial side avulsion of the superficial mcl could be analogous
to as stenner lesion in the thumb. If avulsed and placed superficial to the pes ansernus, one 

cannot expect a stable medial side and hence  acute repair with suture anchors  of both the deep and superficial mcl is warranted. If the posterior draw in internal rotation is exagerated the POL should be also reconstructed as described by Kim or stannad. 

The posteriolateral reconstruction is best done by the method  by the Korean maestro Kim as shown in the figure below

 The timing is controversial. The results from the experts suggest recon within 3 weeks  have the best results. I do agree with my experience (level 4- 60 cases) but qualify that medial side femoral side repairs if attempted intensive physio is warranted to avoid stiffness. Lateral  reconstruction does not have stiffness as a problem unlike medial side. The only need for staged recon is in open injuries where in I would do the collaterals acutely and stage both cruciates simultaneously in 2 to 3 months.

central fracture dislocation hip with intact column and wall

 Here are the unsual pictures of a pure central fracture dislocation with intact coloun and walls. This to me is a rare injury and not classiffied in the present  accepted classification. the columns were congruent. Any comments

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