Infected THR with a sinus

65 year old infected rheumatoid hip with femoral sinus of 4 years duration. The treating doctor told her to walk slowly till she became bed ridden with pain. Any comments

Femoral stem is jammed thru the cortical window, porotic bone and and ofcourse the mushroom shaped acetabular cement mantle.

plan

ETO, 2 stage revision, mobile spacer Plate back up in case of fracture as the bone is porotic. Vascular back up and Ilioinguinal exposure plan ready in case of iliac vessel bleed. Angio with limb movement to see if any kinking occurs. As planned we had all the problems execpt vascular injury. We used a plate to tie the ETO stabilising wires as the cortex was too thin to hold the wires. Iv antiobiotic was given for 6 weeks followed by oral rifampicin. Subcutaneous forteo was given to improve bone quality. she did not return for the second stage revision. My worries include further acetabular bone loss with abrasive wear, breakage of the spacer and rarely dislocation. May be a static spacer could avoid these problems. Sorry, I just heard she had a stage 2 revision elsewhere and is walking.

TKR in a rheumatoid valgus knee with plastic deformity of the MCL.

It was managed by a Posterior stablised knee with medial condylar (not epicondylar) osteotomy, pulled up at 30 degrees flexion to tighten the MCL. I have been lucky. Done well so far 4 years postop. May be a Contrained knee should be kept as a back up in OT

TKR in a patient contralateral hip disarticulation

At the point of loading in a patient walking with a single leg with crutches and no prosthesis, the knee is in 10 to 20 degrees flexion. Possible shear vector at the poly. What would be the ideal joint repalcement. She is 60, a case of osteosarcoma 30 years post diagnosis and now ca breast in remission after chemo.

Do we do a posterior stabilized knee. LCS or a single radii knee like NRG? any comments, suggestions are welcome.
sorry she has a disarticulation of lt hip and now OA of rt. hip

A case send by Dr Sujay for opinion

37 year old rt. handed male (profession unknown) with 8 yr old injury. Is it a SNAC wrist? Early radial styloid scaphoid OA. No DISI. Scaphoid does not seem to be flexed. Not great xrays

Plan

SCope , styloidectomy and if midcarpal and rest of scaphoid is normal. Attempt the nonunion with a vascularised bone graft as the proximal pole appears to be ? avscular. Pt cannot afford an mri.

If finacially challenged, may be a scaphoidectomy and a 4 corner fusion should give him 10 year pain relief if it works. Any other views

jacob

Arthroscopic ankle fusion

18 yr old girl with ankle pain for 15 years. open biopsy done 10 years ago was reported as nonspecific. She had rest pain. Xrays showed consider narrowing of the joint space as well as osteophytes. The plan was arthroscopic ankle fusion. I have performed 14 of these and all united within 6 weeks except one where in resulted in a nonunion (gross deformity was the reason). Due to severe fibrous ankylosis of the joint one could not enter the notch of Harty or ankle. One had to identify the anterior joint with great difficulty. I was on the anterior tibia and walked down under IMI control as there was no joint space to enter. Using osteotomes the joint was entered, scar removed with small curreted and arthrodesed with 2 converging tibitalar 6.5 mm cannulated cancelous Screws.

The biopsy was done 15 years ago and reported as nonspecific synovitis. Xrays- 6 degrees plantar flexion,neutral varus/valgus.

We unfortunately did not biopsy this time. As far as Sunjays comment goes. You are spot on. One cannot correct deformity with arthroscopic ankle fusion and the only failure I had with a arthroscopic ankle fusion is a deformed ankle(1/ 14). As far getting into the ankle is concerned, it is best done with ankle in dorsiflexion, no traction, direct trocar medial to lateral after entering into the capsule at the AM portal (Notch of Harty) in the coronal plane and look posteriorly to identify the joint. The clea8vage even in fibrous ankylosis is visible, if not the under x ray control using a quarter inch osteotome one could identify the same and work posteriorly with osteotome, currettes and vapr etc before fusing it. Long term secondary OA is expected when in further fusion may be needed. TER at this age is not advisable.

Bimal, 1.

The morbidity is less. The patient is home the next day comfortable. The oedema and pain post op in open lasts for a long time.

2. The union rates after scopic fusion is much higher above 95% and even the duration to fusion is less.

the xrays are uploaded for comments

Dr. Sreenath in an aggressive mood during TKA closure.

He is now in pariyaram medical college, Kannur. Could Dr. Srenath comment on the fellowship in lakeshore hospital

.

The board room games will continue. I hope the fellowship goes on. Thanks to my fellows, juniors and colleagues we could make something of the time spent together. My teachers inspired me to share, acknowledge and gather knowledge by all legal methods. Professors like Varghese Chacko, Benjamin Joseph, NJ Mani, Bhaskaranand, Sripathi Rao, Brian O connor ,John stanley, James Richardson etc inspired us trainees. Each, added some other dimension to the attitude ie orthopedics. Team work is the name of the game. The puzzling questions raised by you guys help our degenerate neurons to fire, the addition RAM you guys add to the systems take it further. I remember a slide given to me by Jaithilak before the first Amrita arthroscopic course from the Vedas about knowledge when shared grows, cannot be divided or stolen. The system in LORC where in every member thinks to improve the system whether it is secretary, Maria school of nursing( as Bimal calls it), nurses, doctors, OT tech and all important physio adds serious value. The audits, suggestions and academic presentations push it further. Pray that the good lord continues the work where ever we are with that ATTITUDE. u know what i mean.

jake

IS THERE A ROLE FOR PELVIC SUPPORTING OSTEOTOMY

Pelvic supportive osteotomy both Shanz and Milch bachelor's osteotomy were the mainstay to avoid a trendelenberg gait in the past for paralytic dislocated hips. I understand this is still discussed in the exams and am unsure of its use even in the financially challenged.

Of late we had to convert a spate of these ostetomies to thr. Below is an example. 40 yr old male who had a shanz osteotomy 20 yrs ago, now has pian in hs Lt. hip. Neurologically normal.

1.Was a Shanz indicated?

2. Would a Chiari osteotomy been better at that time?

What now?

We did a perpendicular oseotomy at the level where the 8 mm drill from the ideal proximal entry point exited on the lateral cortex, drill the distal fragment, then sleeve and finally used a unicortical plate for additional stabilisation of the osteotomy(not always need).

Patellofemoral instabilty in 18 yr old girl

We have a 18 yr old aspiring nurse with H/0 of recurrant dislocation patella and peripatellar pain. o/e. She has mild ligamentous laxity, No end point of MPFL with definite medial patellar laxity, +ve apprehension for patellar instabity, normal TT/TG distance, no lateral femoral condyle hyoplasia, bilateral increased femoral anteversion value- 25 degrees. She need to join college in 6 weeks. No instabilty in the opposite knee but has patellofemoral pain(lateral facet)

Do we correct anteversion first or MPFL reconstruction first or do we do both simultaneously. Do we use a IM Nail to stabilse the osteotomy? Not much of a fan of plates.

Had a comment from Dr. Sachin Tapasvi suggesting MPFL first and Big b suugesting de rotation first.

We were wondering whether to do both together. But the patient was advised conservative treatment- Physiotherapy elsewhere> Guys Magic still plays a role in medicine.

to answer sreenath, Axial cuts along the neck and trochanter superimposed on axial cuts at the epicondyle will give us the anterversion.

Arthroscopic PLRI reconstruction

While preparing for a talk on PLRI, I was shown ( By Dr. Biju my colleague) a Chinese article in arthroscopy July issue where in they did a arthroscopic PLRI reconstruction. The description appears doable using a trans- septal portal. Has any body tried it do date.

Total knee replacement after High tibial osteotomy is sometimes challenging, Prior incisions, meta-diaphyseal deformity, interfering hardware, Patella Baja add to the problems. Here is an example of a 20 degree valgus following an HTO 5 years back. any suggestions or comments please.

Here are the postop pics with a metaphyseal osteotomy. Only the interfering screws were removed. Prior lateral skin incision were extended proximally in the midline from the junction of the lateral transverse arm and vertical arm with nil skin problems.

DO WE CALL THIS ORTHOPEDICS

Finally after all the comments. Lets show you what happened. The patient is financially challenged and has INR 10,000. We collected around and decided to revise the the worn out acetabulum as that was causing more pain. Our plan was to remove the bipolar and remove the distal broken stem through a knee arthrotomy and punch it out through the intercondylar notch with an oats recipient instrument induced access. Unfortunately we found some clear fluid from the hip and therefore did not want to contaminate the knee. While waiting for the frozen section, cell count and g stain we did a femorotomy and removed the distal implant. As the femorotomy reached the diaphyseal flare we had to choose a locking stem in this case Reef(HA coated) with ceramic on ceramic bearings . she is mobilising with a single stick now and now wants revision of the dislocated hip which possibly could be done with a primary stem with a large bearing. I would be glad if there are any takers for doing the same as she is broke. She would about 200000 for HARD ON HARD LARGE BEARING THR.The first surgeon who is an orthopedic hospital owner apparently has washed his hands off and lives a semiretired life comfortably.
Points for discussion.
1. Rule out an metabolic cause in a 36 yr old female with bilateral # nof.
2.Adequate fixation of neck of femur. DHS is easy with a derotation screw. A gamma nail may be more indicated in elderly.
3. No role for hemi arthroplasty in young active patients even if financially challenged.
4. Does IMC need to debar and penalise the criminal who did this?
jacob

36 yr old female auxillary nurse sustained what appears a bilateral # neck of femur ( ?metabolic cause) had the following set of surgeries done free by I believe an orthopedic surgeon. The final xrays before revision is on the left and what serial xrays available are below. your comments on what was done and what to do?

ACL Reconstuction.

Over the past 10 yrs there is a rising no of Cruciate ligament injuries at a ratio of 10:1 ACL/PCL ratio. May be the awareness is increasing in Gods own country or the vaidyans are being left out, Even the Vaidyans are asking for MRI before referring or treating the same. The changes in technique in my practise has been double bundle reconstruction when young,sporty and affordable and single bundle reconstruction with the femoral tunnel being at 10'o'clock to better control rotations. AM on tibia and PL on femur. As far as fixation goes we do endobutton with aperture screw on femur and intrafix on tibia. At one year followup we have not seen any functional difference between the two.

My take on bioscrew at both are 1. On the femoral side i end up damaging part of the graft occasionally and on 2 occasion my entire graft pulled out of the femoral tunnel on tensioning before tibial fixation. This has not happened yet with a suspensory fixation like enobutton or transfix.

profound venting by an orthopod

How objective are we when we counsel our patients with regards to options of treatment. The bias one has as we get older, technology availabilty, expertise, ignorance, financial and other benefits cloud ones Lt. frontal lobe.

The way out would be objective independent audits published by the department for the patient to compare the local results with the best international to make a choice. The science editors in the newspapers follow what the advertising company tells them without an indepedent check. The not so recent advert about key hole knee replacement is an example where even The Hindu Newspaper printed the same. The nexus between service providers and customers (MRI, CT scans, lab tests and commission paid to doctors for referral) are compromising the quality of care.

Orthopedic training to pass the exams are akin to entrance coaching( The license to cut). No lateral or objective thinking. The examiners both young and old still want students to mug up all those lines(Chinnies) and tests like Thomas and Bryants triangle etc which has no relevance today. The discussions on objective management are short and swift. Medical colleges both Govt. and private are not being objective to improve and inspire future doctors. If we do not give the best inspired training we ourselves will be the geriatric guniea pig in time.

Relicensing was talked about some time back. At least mandatory seminars to qualify. Not just holiday trips for chilling, wife's shopping etc.. Lectures given from text books which are ancient as atharavveda. Lecturers selected for their age and contacts,marketing potential and not for quality. Conferences to market, advertise and now to make money as one's primary trade is less renumerative or is it multi tasking. Where are we heading?

Jake

36 yr old rt handed male fell down after "ethanol" use on a monsoon weekend. Sustained an undisplaced scaphoid. Postop xrays at 2 months when he is left free of pop. Back to work driving himself. There was communition at the radial and volar border. The xrays out of pop which will be uploaded in due course as the xrays are with the patient. You don't need to removed the screws and if you need to due to infection etc god help us

os with an arse

Middle aged arab male with pain on walking during swing phase of gait and walking down hill of 4 years duration. No gain with conservative treatment.

O/E. Tenderness on the posterior lateral aspect of ankle with minimal pain on Inv/eversion. Pain on plantar flexion and exteranl rotation.

Any options

We did ahind foot scopy as taught by Dr. Van Djik http://www.ankleplatform.com/. The course is rated 10/10. The portals on a horizontal line from tip of the fibula on either side of the Tendoachilles. The posterolateral portal after split and spread technique is aimed towards the first webspace and hit the bone. The posteromedial portal goes perpendicular to the scope in the PL portal and walk on the scope till you reach tip[ and debride the soft tissue till you expose the os , ankle joint and subtalar joint. The os was removed piece meal with a burr, grabber and finally an osteotome to be flush with the posterior tibia. The FHL shown in the pic protects the n/v bundle. stay posterior to it. The relief of symptoms were magical.

This was presented in the Cochin orthopedic meeting By Dr. Rajesh Subash our latest arthroscopy fellow