MPFL anchor points to the red spots

Patella tilt post TKA

My colleague Dr gnanavel has just come out with a paper  that a patellar tilt of more than 10 degrees might be associated with poor out come in TKA when patella specific scores are used to predict the outcome. He suggested that it would  be advisable  to use patellar specific scores in all future studies investigating the ever controversial patella in TKA. So consider merchants or skyline view and melbourne scores to asses anterior knee pain which is ever present if you ask for it in 10 to 30 percent of individuals.

fracture neck 6 yrs post resurfacing arthroplasty

              I was asked what to do next.

It appears the the femoral  metaphysis is abnormal. Is it an old infection or something else? The safest option would be a complete revision to a ceramic on ceramic bearing or ceramic on vit e poly in view of the bad press with metal on metal. The comonest cause of failure at medium term as above is if the primary indication was in AVN. One could consider one of the short stems in the market today like metaphyseal engaging short stems from metha hip from aesculap, silent hip from depuy, taperloc,balance microplasty to avoid the canal compromised deformed metaphysis.But remember these microhips have at best  year results in expert hands.

one needs to be careful to avoid loosing more acetabular bone while explanting the cup. May be the zimmer explant system would help.

MOM bearing in revision - 6 year followup of a type 2 acetabular defect in a 57 year ld lady

 

Chasing the good bone- medialisation to chase the good bone. high hip center 

6 year followup- clinically asymptomatic

Stress shielding

 

2 month old infected supra-intercondylar fracture in a 62 year old diabetic

 

 Infected, with multiple organisms, initially with gut organisms like klebsiella, providentia , E coli etc. Antibiotic treatment ended with pseudomembraneous colitis. They debrided him twice in the OR. The last organism was pseudomonas which was sensitive only to colistin, which he received. Discharging sinus still present

 

 What next

.1 Illizarow in capable hands

2. one final debridement with local stimulan beads with colistin and other "necessary" antibiotics with autologous bone graft  provided the fracture is stable.

any other suggestions welcome

6week old fracture in a bed ridden 92 year old lady

Any comments on mangement of this fracture in a 92 yr old bedridden patient post CVA with bed sores presented to an orthopedic colleague. any comments on manging this case provided the reatives are willing to take the risk.

 

 

1.  Leave alone on splint and analgesia. Cons- die in pain for the last days of her life

 

2.Excise and one stage distal femoral tumour prosthesis. The cons include cost, infection risk and fracture above the stem as well as intraop cement related problems. pros include quick surgery and can  mobilise if ever possible.

 

3. Indirect reduction- supracondylar nail with an addtional locking plate with or without cement to enhance stabilty

any other suggestions are welcome



painful hemiarthroplasty

 

 

 

 

 

 

 

 

 

The pain could be in the groin or thigh. if there is no rest pain it has to be as expected aseptic loosening. I would hesitate to put an uncemented AMP in a physiogical 60 as all evidence points to a THR can get better results if there is  no dislocation

                                                                                                 

One needs to rule out infection with the CRP/ ESR with aspiration and luecocyte esterase test. if not infected a one stage THR. My choice would be  to  do an uncemented cup with vit E poly,36 head and an uncemented fully HA coated  high offset stem if i can get good fixation. I need the opposite HIP xray to measure the offset -green line. if cemented stem is used consider roughening the endostium to  get cement interlock.

 

send at least 6 cultures of tissue,fluid in bactec as well as  check for fungal cultures( remember the cheatles forceps used in some ORs which need to be banned).

End of stem pain in a rev tkr

 This 67 year female presented with start up pain in the knee and midshaft of tibia which was tender. She is close to 2 years post revision.
The pedestal at the tip of stem and circumferential loosening line around the stem and medial tibia suggests that its loose. Awaiting bone scan.
Beware of straigth long tibial stems

My options
1. Revise the tibia  and use a shorter thicker uncemented  stem may be  70 mm Into 16 mm ending at least an inch above the present tip( no scratch fit).
Centralise the reamer with at  sleeve( the type we use for distal cement drilling in  revision stem) pass the  im nail centralised guide wire with an image check and use a central stem.if one is closer to the tip you would need to by pass the end of stem and then might need a curved stem or might get away with a slotted stem.
2.Use a short cemented stem
Ps . I have got away once with a cemented long stem in a RHK knee

break from the present

 Hi,

 I am taking   a break from the present job at LORC  and will return end 2014. In my stint at lakeshore I learned and practised orthopedics to the best of my ability with a team of colleagues  who pushed me further, with staff who took great care of my patients and help collect data and gave critical contribution to improve our quality of care.  Thank you team it was a pleasure working with you and hope to in future. I am sure what we started together,  will be taken up  higher by all of you.

 

 

Any cases mailed  will be replied on the blog without naming the sender unless mentioned.. If you don't want to please mention in the mail. I am not sure whether I will be able to upload cases from the new place i work in oman. Thanks for all the comments and hope at least some of the blogs were useful

jacob

4 months post chaffauer's fracture.

 pain and stiffness rt wrist r in a rt handed cabin crew

Patellar tilt in tkr

Which of these patella will be symptomatic.

Clinical  significance of patellar tilt in post tkr senario is controversial. The knee society score andIKDC did not reveal any signifcant changes with grade 2 and 3 tilt. Dr. Gnanvel looked at patella specific scores to reveal significant difference in grade 2 and definitely grade 3 tilted and subluxed patella. The Melbourne patella scores revealed the significance of tilt and subluxation with lower patellar scores. In the above X-ray there is clear evidence of impingement in the lt patella and grade  2 tilt meaning  more than 10 degrees.
 Would a lateral partial patellar facetectomy  help?
Is the patellar tracking altered by the groove design, surgical tech if the femoral size and rotation is accurate.

Ulno carpal abutment

22 yr old male with h/o injury as a child c/o ulnar sided pain od 3 Yrs duration. Xr and MRI shows 4mm long ulnar + with ? Central tear 

of tfcc with triquetrum. chondromalacia

Plan.

 Wrist scopy  and  if central tear - debride the tear and shave the distal ulna thru the tfcc

If peripheral do a ulnar shortening  and dcp plating with peripheral repair of tfcc.

anterior and posterior impingement of ankle

 This  28 yt old boy presented with pain both anterior medial and posterior laterally. with clinical evidence of both anterior and posterior impingement, confirmed by diagnostic injection

 Would one do both anterior and posterior scopy one stage

Thougths on improvement of orthopedic trauma

 Fellow orthopods,  radiologists and mechanotronists  together could help to improve trauma surgery

 my thoughts are as follows

1. 3 D MRI to asses fracture geometry and  soft tissue attachments of each fragment.
2. Use skill of expert surgeons for their technique in reduction and biological fixation with out further collateral damage and write software for it .
3.Use mechanotronics and external frames to devise indirect robotic reduction techniques using threaded pins and wires plain or the olive kind and all what the surgeon need to do is fix the plate biologically

 your views guys

Musculoskeletal Imaging has to quickly catch up

MSK imaging has improved leaps over the past  2 to 3 years. Use of 3 tesla magnets( minimum of 1.5 tesla). multichannel coils and joint specific coils for ankle. wrist and shoulder, specific sequences for cartilage have improved our diagnostic accuracy.

With insurance companies asking for MRI reports I feel it is mandatory that the imagologists update the skills and machinery to avoid leaving the poor patients troubled. I  have many times seen patients refused insurance clearance for surgery with painful conditions which need surgical intervention  due to incompetent reports and images. Oh yes, insurance  and imaging companies  are there for profit, but that should not affect the quality of care at the point of delivery.

 As for us orthopods and radiologists look at the quality of pics above even differentiating the red and white zones which could help plan repair or menisectomy more accurately.  The radiologists  should quantify,qualify and  classify tears type 0 to 7 types( mesgarzadeh et al /1993.asses size and depth of cartilage lesions in addition to standard ligaments.

 Specific cartilage sequences identify chondral injury in the presence of episodic pain despite "standard normal MRI reports" and asses healing using MOCART scores to be objective about results

 I was pleasantly shocked to see some images from a 7 tesla machine.