Arthroscopic shoulder stabilisation.

Is it the standard of care? Shoulder surgery has grown much in the last decade. Even in the presence of engaging Hill Sach's , soft tissue reconstruction, bony procedures, arthroscopy has a major role.

 

Identifying the precise pathology whether it is ALPSA, HAGL, RHAGL. Bony bankart's, engaging Hill sach's, pathology specific management is the Standard of care. Puttiplatt's surgery is definitely history(arthritis after stabilisation as the tight anterior structure predispose to posterior wear of the glenoid., the role of Bristow's procedure is controversial. Latarjets modified both arthroscopic and open is advised to increase the arc of glenoid extrarticularly in engaging Hillsach's and has the best results to date.

Timing of surgery is more controversial. Do we intervene for the young first time dislocator with a bankarts or immobilise first in external rotation. multiple recurances can give rise to plastic deformation of both the anterior and posterior capsule leading to various techniques to tighten in both directions and centering the head.on nthe glenoid.

Ankylosed knee with patellar fracture - by Sreenath for opinion

54 yr male with trauma history of ankylosis same knee following septic arthritis at 16 yrs of age,diabetes controlled by dietnot willing for tkr as he had thought about it becos of ankylosis earlier and firm on that decision,no pain previously,office job
Questions for academic interest

Should patella be fixed?

Timing of tkr whether now or when?What all Technical difficultis during surg?How is outlook after tkr?

OATS

28 year old male with a focal cartilage defect(10 mm) in the medial femoral condyle. Picked up on a cartigram with a 1.5 tesla MRI. I year postop cartigram showing the articular cartilage of MFC after OATS

Similar defect in the lateral femoral condyle covered by a bioscaphold( Trufit) in a 40 year old man with equally good short term result-18 months

MRI with a D-gemeric software makes diagnosis of cartilage injuries accurate.

arthroscopic decompression of Spinoglenoid ganglion

25 yr old male, Pain ,weakness -7 months insiduous onset
No history of injury. Conservative treatment for 6 months elsewhere
external rotation weakness (rt) shoulder, Wasting of infraspinatus

MRI Confirms an spinoglenoid ganglion. Options include open excision, ultrasound guided aspiration, arthroscopy to adddress labral lesion and ganglion. We Elected to do an arthroscopic ganglion decompression with immediate relief of pain. Surprisingly no labral tears were found and the ganglion alone was decompressed.

We has since then done another similar case where in a large type 2 b labral tear which was repaired.

Infra spinatus wasting

Options of management include

Spontaneous resolution of the ganglion piatt et al j.of shoulder and elbow surgery,2002 (2 pts )
IMAGE GUIDED ASPIRATION OF THE CYSTS (mixed results)
recurrence common , Tung et al j.of roentgenology 2000 ¾ recurrence in 4 months
Open excision deltoid splitting/detachment
intraarticular pathology undiagnosed
Arthroscopic
Snyder et al ,j.of arthroscopy,2006
Iannotti et al,j.of arthroscopy 1996
chen et al j. of arthroscopy,2003

Type 3 b infected open fracture distal femur and proximal tibia

25 year old male with type 3 b open fracture of distal femur and proximal tibia and lateral facet of patella presented I week after the injury with infected ( wound was contaminated with mud and leaves found 1 week after the injury when the patient presented to us).

Repeated debridement daily under epidural 5 times in 6 days followed primary grafting with iliac crest HAP granules soaked in polymyxcin which was sensitive for gram negative enterocooci and E. coli.

The free flaps for the wound failed twice and was finally closed with negative pressure suction and skin grafting
At 6 months with no evidence of infection and the fracture show tricortical bridging. He is mobilised with a single crutch. The range of movement is 0 to 60 degrees with quads tightness.

I believe the local delivery of antibiotics with HAP granules with slow leaching of antibiotics and osteoconduction helped as achieve union without infection by 6 months.

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.