inter prosthetic fracture in a 67 year rheumatoid pt

 The fracture was non healing for 3 months of conservative care elsewhere

To maintain her mobility the options of fixation and femoral replacement was considered as the hip was painful too due to the migration . A THR  link total femur was linked to the previous RHK tibia which was asymptotic

 

superior capsular reconstruction

rt handed 60 year old lady with 4 cm retraction gautlier grade 3

post op 3 months thanks to physio Sreejith's efforts post op

painful dislocated rt shoulder in a 76 year old lady

Mri showed chronic cuff tear grade 3 gautilier

 with subscap tear 

 The issue  of  reverse shoulder was easy as she has pain and was unstable due to cuff tear arthropathy with thrice weekly dislocation during sleep. Before the arrival of Grammonts prosthesis,  fusion could have been the only option

superior capsular reconstruction  have come recently from Dr. Mihata, however as there is already cuff arthropathy, pain at rest may not relieved.  Capsular reconstruction would improve movement but not increase strength and in this case the instability sealed  the solution.

The next problem whether a constrained liner was needed  or a subscap repair was mandatory or desirable. In this case as subs cap was retracted  further to try repair a constrained liner was use  and the result  is below

6 year post hybrid technique in rt periprosthetic fracture femur

The rt hip under went distal cementing and proximal uncemented in a 80 year old lady who presented 6 years later with no local issues in the hip. This was considered a quick operation for an elderly peri prosthetic fracture for early mobilisation with an uncememeted hip. the porocoat distally was removed to reduce the stem cement bonding.Happy to see no major lysis or sinkage 6 years down the line

posterior dislocation 2 year post posterior stabilised knee

This happenned while she was getting up from a foot stool like devise ( possible high flexion). felt a clunk and could not walk. presented with an FFD of 30 with no further flexion or extension with xray below showing subluxed knee.
 Under GA  it reduced in full flexion and anterior force ie anterior draw and was stable with no further instabilty or laxity, no clinical laxity in any range.  This was the first time I saw this and hope fully the last time. so watch out high flexion guys who show videos of squats and more ? She is 6 months post reduction with no further issues yet

meniscal repalcement

26 yr old male with 2 year post acl tear medial meniscal  was in bits except an intact  root and  a peripheral rim was intactInspite of ACL a reconstruction the evidence of impending osteoarthritis  made us consider a meniscal replacement when  transplant was unavailable.  He is two year post op with no symptoms to date recent mri shows still some tissue perisisting although smaller than immediate postop

nail plate devise

An out line on the design and rationale of the nail plate device for stabilising a periprosthetic fracture of distal femur in total knee replacement-       Dr. Jacob Varughese

 Displaced supracondylar fractures (type 2) needs to be properly aligned and stabilized for an optimal outcome. Stabilization using intramedullary nails, locking plates, external fixators have been described.  The small porotic distal fragment precludes stable fixation with either plate or nail  to commence immediate mobilisation. 

Design of a nail plate  device

In 2009 following difficulty in stabilising these distal femoral fractures  combination of a separate  Intra medullary nail  and a locking  plate  was used to stabilise and mobilise the elderly  above mentioned osteoporotic fracture. This was  repeated in  bilateral case where in the nail was removed  to pass the distal locking screws  from the plate resulting in translation of the distal fragment ref  pic 4  below.  Both the fractures healed in 3 months and the patient was mobilised weigth bearing

Procedure

Knee replacement incision.

A supracondylar nail 9 mm in diameter was passed through the distal fragment  and using this to reduce the fragment and pass it retrograde into the proximal fragment. This avoids soft tissue stripping and quick reduction of the fracture in anterior-posterior and medial lateral planes  with out soft tissue stripping associated with reduction with a plate device. This nail devise could be locked proximally and distally if possible or at this stage a locking plate is passed through a MIPPO technique on the lateral side and locking screws can be applied distally though the incision and percutaneous screws can be applied proximally. In the case  in picture 3 on the right knee the nail was removed after the plate was applied distally to facilitate  screw insertion resulting in translation in the medio-lateral plane. Therefore it was decided to use both nail and plate in 3 further cases where in we obtained stable reduction to facilitate immediate mobilisation.

 With these results we attempted to design a new implant ( nail plate device) to improve the technique and rigidity of  fixation

hybrid technique in periprosthetic femoral fractures

This patient had cementing of the distal half of the uncemented porocoat stem with wiring around the proximal uncemented part  for a periprosthetic fracture 6 years ago
Doing well so far  with no lysis so far
I did expect loosening on the cement bone interface but luckily no lysis so far

 so this is an option in a elderly periprosthetic fracture

 similar case below
http://knee-replacement-india.blogspot.in/2009/12/perprosthetic-fracture-in-octogenarian.html 

Root tears of meniscus

  60 year old lady with sudden onset sharp pain  lt knee. She was previously asymptomatic and very active. clinical exam revealed strong medial meniscal signs  and MRI showed a meniscal extrusion with radial tear adjacent to root.
 she was send for a week of physio and 3 days of NSAID and was reviewed .  she had complete relief and had no meniscal signs and was even able to squat

 After repairing every  root tear  I saw I sometimes think whether I over did the same. Meniscal extrusion remained in at least 3 of the 12 1 repaired in the last 2 years. Pt were definitely asymptomatic.

 To avoid extrusion do we now need to start centralisation sutures like the japs.
Spare a thought guys.

POPLITIOMENISCAL FASCICLE TEARS

Did we miss this injury in the past. The fascicle move the lateral meniscus dynamically during the lateral femoral condyle roll back. one needs to repair it all inside or with a suture lasso as shown  in arthroscopic techniques. to diagnose the same on mri is sometimes difficult.

Pt complaints of a pop sound or locking.
Laprade figure or four test yield is negligible in my hands so far
 most accurate diagnosis is introp, the meniscus can be displaced anteriorly by more than 50% of its width . one might see some chondral defect adjoining to the popliomeniscal fascicle deep to the meniscal

 one could use a mid lateral portal  to repair the same

use of constained TKR implants in BMI above 40

After seeing a small series of delayed mcl injuries in high flexion, high BMI TKRs and similar issues in published in arthroplasy journal ie; 12 percent in high bmi series in my thoughts and solutions changed

 In heavy individuals  I would use stems and  varus/valgus constraint  devise to

1.To decrease stress at the implant cement and bone interphase

2.To avoid stress on the MCL whose delayed ruptures are reported in high BMI  individual

3.To  ?? reduce anterior subluxation of the tibia in flexion past 70 degrees when the calf and thigh meet and creating an anterior vector ( do we need a anterior and posterior stabilised implant here (food for thougth)

I

used the  Exprt revision  knee implant(DJO) with   vit E poly insert as this is the only constrained system where Vit E poly is available where in one can hopefully reduce wear

 They have a simplified 2 tray revision system which   reduces the complexity of revision surgery Iin OR to reduce errors if  the defects are not huge.

medical management of osteoarthrosis

 The basic science guys have been working hard to help  reduce the osteoarthritis disease burden. Every week a new possible solution is talked about.  From microbiomes to ginger, ,curcumin,
Intra articular human   lubricin Inj  to glucosamine with NAPA to reduce cartilage degeneration
 The FDA approval of mri as a tool to asses disease progression for trials will open up research  and pace of new disease modifying drugs appearance in the market will increase. hopefully the quaks will get exposed. With MOCART 2 grading the results can be better evaluated.

is repair better than reconstruction on the medial side in MLKI 3m injuries

 The results of medial repair did  better than reconstructions in my series so far. In the lateral and plri reconstructions gave near normal results. This was discussed with few of panel of experts privately at the ISAKOS. Few disagreed with my view.  my reconstructions have been with semitendinosis and not tendon Achilles  which is broader.

1. Did this alter the results?
2. Is it because poplitius  is intra articular while mcl is extra articular ?
3. Is it because of the adhesions between the layers of the medial bursa?
 used LAD in 2 cases so far on the medial side repairs with good results so far

 Do others agree with my  comments or have a  other experience

PL bundle reconstruction

Isolated pl bundle tears associated with instabilty ie; pivot shift happens  wherein lachman  is negative. In such cases isolated pl bundle alone recon I believe is advisable without damaging the am bundle.

thr in acetabular fracture

 38 yr old 2 yrs  post acetabular fracture and supracondylar fracture presented with pain and stiffness.  no free movements plan was to remove proximal femoral screws and any acetabular screws  interfering with the cup

 

 templating done by Dr. kattab who is my colleague

The two independent screws were intraarticular transfixing the  head  which had to osteotomised in situ. and a primary ceramic on ceramic hip was done. introp frozen section and cultures were taken/

1 . retained implants
2.infection
3.deformed acetabulum
 3.nonunion with dissociation or  resorption
4.cavitatory or segmental defects
5.HO
6.neurological deficit
7. Impaired musculature

if you asses the results one can find the following
 symptomatic acetabular loosening is higher
 uncemented  cups do better at medium term.
neurological defecits, HO are higher. Cavitatory defect can be filled with morcelised bone grafts and impacted or reverse reamed. Majority host bone contact should be at least 70 percent if possible specially in the wt bearing zone. Avoid large grafts as  they do not revascualrise completely and might fail in the medium term. In case of dissociation cage cup combo bypassing the defect would give reasonable 10 year results. Recently distraction of the dissociation stabilized by cup reinforced by cage and a cemented cup has been proposed and published by paprosky