Trochleoplasty

Trochlear dysplasia as classified by Dejour gives us a guideline on management

 B and D need removal of the bump and lateralisation of the trochlear groove and deepening plasty. the results as far as dislocation are satishfatory but pain and long term OA chances are still grey

the case below is a 3o year old female with  recurrent patellar instability with lax mpfl and trochlear dyspalsia

 

 

 The Results of  acute reconstruction of multiligament knee injuries are mirroring single ligament reconstruction when done acutely one stage all ligament reconstruction and immediate ROM  with braces.

Medial side acute repairs and now we attempt scope assisted repairs seem to do better than reconstruction.

In  lateral side reconstructions do better. Fibular based if tibiofibular joint is normal (arcerio)-fibular based lcl  and poplitius recon or Kim technique if Tibiofibular  joint is also injures which is a tibiofibular based rconstruction

 We need to add meniscal avulsion injuries to this classification 

74 year karate instructor with osteoarthritis hip

Issues of full ROM and wear were the issues discussed with the patient, He had to continue with his Karate. His bone looked good being in a physically active  person.

 Dual mobility with ceramic head was selected.

 Size 12 Evolutis stem, largest available in India was found to to stable on axial and torsional loading intraop  and -3 head and Dual mobilty was used due to his extreme ROM requirement

He starts doing karate kicks 3 rd day in ward before discharge and sinks by 2 cm and  now painless and short limped lurch. may be one should have cemented taking the risk of cementation in elderly. his canal was not stove pipe and felt good. Size 12 limitation may be an an indication for cement.

 a cemented DUAl mobility like below would be the solution in soft bone. Collared corail stem might hold some value but could swing instead of sinking

type 3 acromioclavicular dislocation in a rt handed policeman

options

1. conservative. the results of conservative equal surgical

In type 3. 4 , 5 ,6 surgical might have better results

 Patient was advised surgery elsewhere and had a relative with symptomatic ?acjt subluxation with symptoms  and was pushing for surgery. Not sure the indication that pt wants surgery as an indication is  acecptable. Was given independant literature and time to rethink. Came back saying surgery is what he wants.

 So plan was for stabilisation with implants (dog bone) and  semitendinosis graft for Conoid, Trapezoid and anterior and superior acjt lig reconstruction. 5 mm excision of lateral end of clavicle was done to avoid acjt symptoms lateral. there are reports of leaving the joint alone and also removing only the acjt disc. only the conoid was drilled thru clvicle as was worried about 3 drill holes in clavice and fracture seen in another pt. A small superior  subscap flap tear was seen on scopy which was missed on MRI

 

 The 2 red circles are where the graft was knotted and reinforced with fibre wire sutures

Few questions remain if surgical tt is planned

Do we tighten the dog bone first or the graft

Excision of acjt- was it necessary

Weaver and Dunn procedure is abandoned

 

SNAC wrist Stage 3(Vender)

28 YEAR RT HAND MECHANICAL ENGINEER PRESENTED WITH PAIN 4 YEAR Rt WRIST WITH DIFFICULTY IN LIFTING OR GRIPPING HEAVY OBJECTS 

Dorsiflexion - 22 deg (R) / 40 deg (L)

Palmar flexion - 18 deg (R) / 70 deg (L)
Radial deviation - 15 deg (R) / 30 deg (L)
Ulnar deviation - 17 deg (R) / 40 deg (L)

GRIP STRENGTH (avg of 3 values)
(R) - 64.5 lbs
(L) - 72.4 lbs

 

Scopy confirmed severe radioscaphoud OA more on the 

 styloid and early lunatocapitate OA

Scaphoidectomy and 4 corner fusion was done and. At 3 months he has 50 percent reduction in palmar flexion more or less same grip strength and satisfaction of 6/10. Awaiting 6 month review for better function

Good Times- when passion sans politics worked

The core of the first team I worked with  in Kerala, Amrita institute where most of us in the  team above worked with passion (Orthopedic I meant)  to put Kerala Orthopedics on the cutting edge. Thanks to the support of the management, the staff and the young team where we worked  with critical review every morning of what we did, achieved a lot and pushed for a lot of changes without compromise in the Orthopedic field in our country.  

 

Another way to treat mucinous cyst and ganglions in ACL

Options for painful cystic degeneration in  acl include

Excision and reconstruction of ACL

Multiple punctures  with needles and shaver for healing respone

Multiple punctures and intraligamentous  microfracture done below show quicker healing

Pics left to right preop, 2 weeks and 6 months post op

Back at sports

45 year old Coxa Vara with secondary OA

 

ISOLATED PATELLAR LOOSENING AT 2 YEARS POST knee repalcement

immediate postop 

2 year postop

\

immediate postop

 2 years post

Could not understand the cause of early patella loosening at 3 years post op. The surgical notes  and video were reviewed to look for intra-op issues and found none. No history of falls. History of intensive physio and opposite foot surgey cannot clearly explain the cause.

Intraop, the patella appeared A concave thin shell 6 mm thick at its deepest point and 10mm thick at its thickest point at the edges.

Gull wing osteotomy, Trabecular metal patella augment, allograft are the options. we decided to go for Rebarr patellar technique  as descibed  using  maxillofacial cortical screw as seen below and cemented a patella over it. at 3 months she is still good

McPherson EJ, Sherif SM, Dipane MV, Arshi A. Patellar Rebar Augmentation in Revision Total Knee Arthroplasty. J Arthroplasty. 2021 Feb;36(2):670-675. doi: 10.1016/j.arth.2020.08.057. Epub 2020 Sep 1. PMID: 32951925.

 

BILATERAL Dysplastic hips treated corail ddh stem and COC bearings 32 mm

 

DDH in an young hypermobile patient with pain

 Chasing the good medial bone with a posterior vector one could get a 48 mm cup and  28 COC bearing and an srom stem . she prsented at 6 weeks psot op with a dislocated hip without any symptoms oer episode at home. she  was ofcourse NWB but even then the without a  notable incidentthis was worrying. she had hyperlaxity in elbows and knee and was an avid dancer pre pain

Intraop the femoral version was changed to neutral or a touch retro  to remove the perceived impingement  at 3 month month surprisingly no abductor lurch and improvement in pelvic tilt

45 yr old neuropathic knee with pain and instabilty

The options of arthrodesis, wait and watch and rotating hinge was discussed. RHK had the best published results  however an 80 percent survival at 15 years was mentioned. An attempt elsewhere at regenerative medicine was attempted elsewhere which was surprising