Tibia Vara Causing OA knee

63 year old lady 14 years after conservatively treated diaphsyeal fracture tibia presented painful knee with medial and patellofemoral OA

Planned to do a metaphyseal corrective osteotomy followed by a TKR- one stage and grafting. Touch wt bearing for 6 weeks. Fibula was not osteotomised as adequete correction and compression and grafting was thought to be sufficient.

79 year 10 years post acetabular fracture fixed elsewhere presented with Trochanteric fracture. Patient ASA grade 2, non diabetic and pretty active. The judet views showed adequate posterior column and wall. Planned for a THR. Cemented or uncemented. 36 head if possible.

We decided to remove the implant only if it was interfereing and finally went thru modified hardinge and did a cemented repalcement. We wanted a larger head diameter with an uncemented cup but due to the presence of 2 intraarticular screw we cemented the same and a calcar replacement stem with wiring of the trochanter.

21 YR OLD RT. handed student presented with a stiff elbow, jog of rotation Fixed at 90 degrees flexion. She was immobilised in the primary institution for 3 weeks following dislocation which she was mobilised.

Alkaline phosphatase is normal.

MRI shows some radiocapitellar bands

68 year old patient with metaphyseal varus deformity of 22 degrees . Planned for TKR.

Is there a need for a metaphyseal osteotomy? An intraarticular correction of more than 10 degreees may be not advisable,both for longevity as well as medial cortical impingement.

We did a transverse metaphyseal osteotomy where the intramedullary stem impinged the cortex( below the stem tibial base plate junction), used an intramedullary tibial cutting jig. used a distal fitting intramedullary stem and cancellous graft was impacted at the osteotomy site.

She was commenced mobilisation with a walker for 6 weeks.

78 year old gentleman, hypertensive and well controlled diabetic sustained a both coloumn fracture rt. acetabulum following a fall down the steps. Relevant 3D pics are attached.

















Comments please

In view of his age and communition we planned ORIF and primary THR. His haemoglobin was 8 gms we made us think of 1. fixing the posterior column and wall and use a multiholed cup if good,stable posterior superior host bone contact is obtained or 2.cage if we cant get the same.





attached are the pics with good posterior superior contact and primary THR. Host bone autografy used medialy to avoid protrusio.
On your rt is the 3 month xray and is now full wt bearing> no migration detected yet.

54 year DDH

54 year DDH with pain rt. hip, Gross trendelenberg gait and 7 cm shortening.

Options
1. Milch Batchelor osteotomy if the patient is financially challenged to avoid trendelenberg gait and excision of the head if one believes that as a cause of pain-
2. THR with a modular stem with subtrochanteric shortening

Problems with THR- Solutions
Finding the true acetabulum- Standard hardinge exept the proximal limb in an acute angle to follow the gluteus medius fibres. Neck osteotomy as planned. Follow the inferior capsule from lesser trochanter to reach the true acetabulum or walk on the ilium with a Homan distally till you slip below the transverse ligament, all the while excising the scar.
acetabulum with narrower AP diameter as compared to supero inferior diameter.Thin or deficient anterior wall.- Drill the medial wall eith a 2.5 drill and measure the depth usually 1 to 1.5 cm. That is how much you can medialise the cup or even break the medial wall as described by Zhiang. Use the next reamers in the inclination and version decided with a posterior vector to ream less of the anterior wall till one gets a good fit not just superior inferior fit. 70% host bone contact is achieved without much ado.
Osteoporotic acetabulum as it was never loaded - .I had a problem in one case when the acetabular dome screws cut out when mobilising the patient and had to cement a cup. So keep Cemented cup back up.

Shortening of femur - well descibed techniques in literature- shall elucidate if needed without boring others with this writen diarrhoea.
Narrow canal
Proximal distal mismatch
2 yr follow up xrays after the weekend
As a reply to Dr. Utkarsh comments. To find the true acetabulum after the osteotomy force the spike of the homan;s spike on the ilium and excise the scar. Walk down on the ilium with the spike feeling the bone till you come to the deficiency inferiorly which is the tear drop.

As far as the stem goes I use a modular stem which is distal fixing and proximal loading with sizes upto 6m and small offset to cover for the narrow canal. The distal slot helps to hold the distal fragment after the shortening osteotomy and rarely a unicortical plate is needed.

There ia a latin american paper where in a distal shorterning osteotomy is in the metaphysis ( supracondylar)with similar results. Others have desribed a method to Intesucept the distal smaller dia fragment to the larger dia proximal fragment for stability. We use a sagital osteotomy of the shortenend excised fragments as a vascularised graft with V. lateralis attached to lie on either side of the osteotomy as seen in the above xrays.



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perprosthetic fracture in a octogenarian-

perioprosthetic fracture in an 89 yr old male after Austin moore prosthesis implanted 3 years ago. COPD, H/0 recent CVA.


Ideally I want an implant which is cemented distallt and uncemented proximally for fractur healing and immediate mobilisation in view of his age. What was done was a fully porocoated cobalt chrome implant here in the porocoat was removed with a burr smoothen the stem for cementing distally and wiring proximally in the uncemented part. Patient was mobilised immediated post op with a walker wt bearing as comfortable. He is 8 months postop so far with no lysis. bipolar head used as the acetabulum was normal and low demand.

Hey I did a Restoration fluted stem revision yesterday- which may be an option here as it is titanium. fluted with grooves like wagner to fit distally and HA coated proximally for this octogenarian for immediate wt. bearing.

To fix or replace -5 month old fracture dislocation

Dr. Ramesh Dalwai sends a case for discussion

This a 55 yr old gentleman ( rt. hand dominant) with H/O fall 5 months back. Sustained injury to Rt shoulder and was treated by a bone setter. Presented to His OPD with difficulty in overhead activities and ADL:

Gross wasting,ROM- Flexion upto 60 degrees,No Extension or External rotation, Abd -40 degrees. All movements associated with terminal pain only.No neuro-vascular deficits.

Any comments or tips on management

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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