Anterior impingement of ankle

 

 

 Patient with anterior pain on dorsiflexion exacerbated with anterior joint line presssue. Anteriomedial oblique xrays show the impinging osteophyte

arthroscopic management of meniscal root avulsion

 The issue if a menisectomy is done for root avulsions the chance of OA increases much higher than a partial menisectomy invoving the body. hence currently the advise is to repair them and protect the repair without wt bearing fo 6 to 8 weeks. It this case may be 2 sutures would improve the hold

Failed ACL reconstruction

Any takers on management and technique

 My options given to the patient.
 1. Scope remove the intra articular screw ASAP and do a revision ACL. However I warned him that in case of severe OA one might consider not doing an ACL. One could envsage problems only with the tibial tunnel screw. I plan to the tibial tunnel entry more medial exiting at ht lateral half of the medial tibail spine. Femoral tunnel isnt a problem as the previous tunnel is vertical.


Post op pics are below. The screw had damaged the medail edge of the lat femoral condyle adjacent to the notch( Like a wide notch plasty)

post acetabular fracture - post milch batchelor osteotomy

Case for opinion-
This 52yr old gentleman had girdlestone followed by shanz ostetotomy in 1995 for neglected fracture dislocation left hip.
Now he complains pain around same hip and wants THR

Bloods are normal
The senders  plan is for uncmented Depuy ceramic on poly with S-ROM stem.

Will he need Subtrochantric shortening Ostetotomy?

 

My view is

1. I need judet view/CTscan to see the acetabulum the posterior colum and wall in particular

2. intraop specimens for frozen section and culture

3.Looking at the AP a primary acetabular cup is possible.

4. I wouldnt do an SROM as in a similar case the corrective subtroch osteotomy went in for nonunion as SROM is essentially a distal fitting stem  and the hold on the distal fragment is not rigid as a distal loading stem like Solution or Echelon

5. You wouldnt need a shortening most likely but would correct the deformity where the central axis of the proximal fragment(Red Line)  reaches the medial shaft- an opening variety(ORANGE IS THE LINE OF THE OSTEOTOMY PERPENDICULAR TO THE RED LINE) and ream and hold the distal fragment tight with solution or echelon COCR stems . graft the result defect with the cancellous graft> plrase strip the v lateralis only at the osteotomy keeping the  muscle  through a vertical split maintaing the the  extramedullary blood supply of the distal fragment. 

TKR in postraumatic stiff painful knee

 63 yearold  lady with post traumatic arthritis- 5 years post open type 2 fracture tibia  treated primarly by illizaro and  screw presented with pain and 0 10 to 30 degress rom. No sinuses. ESR and CRP normal.. Multiple scars on the proximal tibia as sequelae of open fracture. Never had sinuses postop. Piperacillin- tazobact  with CAPO4 pellets were introduced into tibial canal  to combat bugs if any and a fractional lengthening of quads was done.to obtain 100 degrees flexion.

 We used an offset stem. Long stem was avoided so as to avoid further osteotomy inscisions as well as to avoid exposing the luscent ares of tibia.

 Introp frosen section and leucocyte esterase tests were negative.

33 yer old male post osteotomy for opinion from dr. rajesh

Ensure that the pain is from the hip itself as the lateral joint space is reasonable although inferiomedially it looks narrower. If in doubt put  local in the hip and reasses pain relief. 

ANY takers for FAI here- SCOPE and proceed

 If a THR is planned 1would consider the follow Problems including  insitu implant- remove the scews  after dislocation to avoid intraop fractures. the plate can be left alone. sometimes one might be able to put a small stem between the screws in cemented situation. Send intraop cultures

 the stem  should ideally be longer then the plate to avoid postop fractures.

some doctors use  preop SWD to heat the implant to loosen it preop, other heat the screws with the cautery to loosen the screws.

keep broken screw removal kit in case of problems and include the philips head screw driver  incase of older generation screws

2.  Varus neck with a shorter neck. bigger offset stems  would help to maintain the abductor tension as well as to prevent lengthening in case of  using a hard on hard bearing obtaining a tight reduction and avoid stripe wear.

 longer  stem preferbly modular proximal loading stem like SROM to make revisions easier in case of  ceramic head fracture. one could use a longer cemented sem like exeter with offset options.

3. avoid introp and postop fractures.

as far as your questions on entry point to avoid varus stem.

I would extend a line proximally on the xray as shown below from the medial edge of lateral cortex of the diaphysis and measure it from the lateral trochanteric cortex(orange Line) to make it your starting point introp. some companies have a lateraliser instrument to further lateralise the entry.

good luck

Ossron(cultured osteoblast) in AVN hip

Above is the xray of a 28 year doctor with pain in lt hip of 3 months duration. The mri showed a gr 2 lesion in lt hip and grade 1c rt hip. We attempted acteocyte culture and at 5 weeks the postop xrays are below. We are awaiting MRI pics to look at revascualrisation. His symptoms are better but that could be due to decompression alone.

 pleasantly surprised

 

Complex Hip- OA with intertroch nonunion with implant in situ

Any takers for this complex hip pics send to me by my good friend 

 He managed put a stem  between the screws had a problem with the  osteopenic trochanter and possibly cup both of which could contribute to instabilty which is what happenend  in time

 Charan whats the problem now and solutions
 as expected  the hip dislocated

The options now
The cup appears too anteverted as well as vertical. . with a flying trochanter adding to the problem.

 my advise is to revise the cup. use larger head if possible and use a trochanteric cable plate.if the troch is too soft to hold  wire over a titanim mesh. if this does not work only a capture cup or a tripolar head is the only solution.

My friend revised the cup and stabilised the hip. his trochanter has dissapeared. In this situation anchor the glutea to the reamaning bone or if that is not possible anchor the two flaps of TFL  to bone  leaving the distal portion free to inset distally. Abductor bace for 6 weeks

11 years post Single bundle PCl reconstruction

 I had the pleasant surprise of  reviewing a patient 11 years after a single bundle Quads tendon isolated PCL reconstruction done while I was at amrita institute. He has no symptoms and works as a project engineer in the oil feilds of oman.
o/e.
PCL was close to gr 2 solid end pt. no meniscal signs or joint tenderness Dial test negative. Xrays show minimal medial compartment narrowing as compared to the normal side. No patellofemoral changes.

Inspite of old technique the PCL recon was worth in a young man. I believe the present day literature support even in isolated PCL injuries more than grade 2.

My

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

\

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