meniscal repalcement

26 yr old male with 2 year post acl tear medial meniscal  was in bits except an intact  root and  a peripheral rim was intactInspite of ACL a reconstruction the evidence of impending osteoarthritis  made us consider a meniscal replacement when  transplant was unavailable.  He is two year post op with no symptoms to date recent mri shows still some tissue perisisting although smaller than immediate postop

nail plate devise

An out line on the design and rationale of the nail plate device for stabilising a periprosthetic fracture of distal femur in total knee replacement-       Dr. Jacob Varughese

 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.  The small porotic distal fragment precludes stable fixation with either plate or nail  to commence immediate mobilisation. 

Design of a nail plate  device

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 ref  pic 4  below.  Both the fractures healed in 3 months and the patient was mobilised weigth bearing

Procedure

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 side and locking screws can be applied distally though the incision and percutaneous screws can be applied proximally. In the case  in picture 3 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

hybrid technique in periprosthetic femoral fractures

This patient had cementing of the distal half of the uncemented porocoat stem with wiring around the proximal uncemented part  for a periprosthetic fracture 6 years ago
Doing well so far  with no lysis so far
I did expect loosening on the cement bone interface but luckily no lysis so far

 so this is an option in a elderly periprosthetic fracture

 similar case below
http://knee-replacement-india.blogspot.in/2009/12/perprosthetic-fracture-in-octogenarian.html 

Root tears of meniscus

  60 year old lady with sudden onset sharp pain  lt knee. She was previously asymptomatic and very active. clinical exam revealed strong medial meniscal signs  and MRI showed a meniscal extrusion with radial tear adjacent to root.
 she was send for a week of physio and 3 days of NSAID and was reviewed .  she had complete relief and had no meniscal signs and was even able to squat

 After repairing every  root tear  I saw I sometimes think whether I over did the same. Meniscal extrusion remained in at least 3 of the 12 1 repaired in the last 2 years. Pt were definitely asymptomatic.

 To avoid extrusion do we now need to start centralisation sutures like the japs.
Spare a thought guys.

POPLITIOMENISCAL FASCICLE TEARS

Did we miss this injury in the past. The fascicle move the lateral meniscus dynamically during the lateral femoral condyle roll back. one needs to repair it all inside or with a suture lasso as shown  in arthroscopic techniques. to diagnose the same on mri is sometimes difficult.

Pt complaints of a pop sound or locking.
Laprade figure or four test yield is negligible in my hands so far
 most accurate diagnosis is introp, the meniscus can be displaced anteriorly by more than 50% of its width . one might see some chondral defect adjoining to the popliomeniscal fascicle deep to the meniscal

 one could use a mid lateral portal  to repair the same

use of constained TKR implants in BMI above 40

After seeing a small series of delayed mcl injuries in high flexion, high BMI TKRs and similar issues in published in arthroplasy journal ie; 12 percent in high bmi series in my thoughts and solutions changed

 In heavy individuals  I would use stems and  varus/valgus constraint  devise to

1.To decrease stress at the implant cement and bone interphase

2.To avoid stress on the MCL whose delayed ruptures are reported in high BMI  individual

3.To  ?? reduce anterior subluxation of the tibia in flexion past 70 degrees when the calf and thigh meet and creating an anterior vector ( do we need a anterior and posterior stabilised implant here (food for thougth)

I

used the  Exprt revision  knee implant(DJO) with   vit E poly insert as this is the only constrained system where Vit E poly is available where in one can hopefully reduce wear

 They have a simplified 2 tray revision system which   reduces the complexity of revision surgery Iin OR to reduce errors if  the defects are not huge.

medical management of osteoarthrosis

 The basic science guys have been working hard to help  reduce the osteoarthritis disease burden. Every week a new possible solution is talked about.  From microbiomes to ginger, ,curcumin,
Intra articular human   lubricin Inj  to glucosamine with NAPA to reduce cartilage degeneration
 The FDA approval of mri as a tool to asses disease progression for trials will open up research  and pace of new disease modifying drugs appearance in the market will increase. hopefully the quaks will get exposed. With MOCART 2 grading the results can be better evaluated.

is repair better than reconstruction on the medial side in MLKI 3m injuries

 The results of medial repair did  better than reconstructions in my series so far. In the lateral and plri reconstructions gave near normal results. This was discussed with few of panel of experts privately at the ISAKOS. Few disagreed with my view.  my reconstructions have been with semitendinosis and not tendon Achilles  which is broader.

1. Did this alter the results?
2. Is it because poplitius  is intra articular while mcl is extra articular ?
3. Is it because of the adhesions between the layers of the medial bursa?
 used LAD in 2 cases so far on the medial side repairs with good results so far

 Do others agree with my  comments or have a  other experience

PL bundle reconstruction

Isolated pl bundle tears associated with instabilty ie; pivot shift happens  wherein lachman  is negative. In such cases isolated pl bundle alone recon I believe is advisable without damaging the am bundle.

thr in acetabular fracture

 38 yr old 2 yrs  post acetabular fracture and supracondylar fracture presented with pain and stiffness.  no free movements plan was to remove proximal femoral screws and any acetabular screws  interfering with the cup

 

 templating done by Dr. kattab who is my colleague

The two independent screws were intraarticular transfixing the  head  which had to osteotomised in situ. and a primary ceramic on ceramic hip was done. introp frozen section and cultures were taken/

1 . retained implants
2.infection
3.deformed acetabulum
 3.nonunion with dissociation or  resorption
4.cavitatory or segmental defects
5.HO
6.neurological deficit
7. Impaired musculature

if you asses the results one can find the following
 symptomatic acetabular loosening is higher
 uncemented  cups do better at medium term.
neurological defecits, HO are higher. Cavitatory defect can be filled with morcelised bone grafts and impacted or reverse reamed. Majority host bone contact should be at least 70 percent if possible specially in the wt bearing zone. Avoid large grafts as  they do not revascualrise completely and might fail in the medium term. In case of dissociation cage cup combo bypassing the defect would give reasonable 10 year results. Recently distraction of the dissociation stabilized by cup reinforced by cage and a cemented cup has been proposed and published by paprosky



Hoffas fat pad

The anterior fat pad has been the villian as a cause for pain and arthofibrosis for long. Was it because it has highly vascular, neural and now believed to contain mesenchymal stem cells. With its rich vascular anastomosis it could be the pericytes here, the major store house for MSC. The smart guys at Osaka are already culturing MSCs from fat pad.

It it time to think of using fat pad derived cells in repair of meniscus , acl reconstruction etc.

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