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Trauma & Orthopaedics Revision
ADULT RECONSTRUCTION - Go to Main Contents
Commonly occurs between 20 to 50 years of age. 50% are bilateral. Commonest aetiology is idiopathic, next commonest is corticosteroid use.
Staging Ficat and Arlet staging uses radiographic views. Four stages. ARCO (association Research Circulation Osseous) has standardised the Ficat classification with the addition of MRI.
Stage 0 - Histology positive
Stage I - Normal radiograph but MRI is positive
Stage II - Sclerosis on the x-ray but no subchondral collapse
Stage III - Subchondral collapse
Stage IV - Arthritis
Treatment:
StageI & II - Core decompression;
Stage III and IV - Osteotomy, salvage procedure, arthroplasty
Can be either reconstructive or salvage.
Assessment is mainly (a) clinical (b) radiographic (c) three dimension CT scan
INTERTROCHANTRIC OSTEOTOMY OF THE FEMUR
(1) Sourcil, is horizontal subchondral density and is a feature of normal physiologic loading
(2) Gothic arch is the remodelled bone supporting the acetabular roof with the sourcil at the base
(3) Increased sclerosis at the edge of the acetabulum suggests lateral over load, also look for large lateral osteophyte
(4) Look for large medial osteophyte on the femoral head otherwise called capital drop, which may be an indication for valgus osteotomy
(5) Pre-operative evaluation, patient selection, acceptable passive range of motion are essential for the success of proximal femoral osteotomies
(6) Cumulative necrotic sector angle less than 2000 in AVN has shown favourable outcome after proximal femoral osteotomies.
PELVIC OSTEOTOMIES
(1) Reconstructive pelvic osteotomies or salvage procedures
(2) Radiographic evaluation for acetabular index more than 300
(3) Centre edge angle of Wiberg less than 200
(4) Periacetabular osteotomies for hip dysplasias, Ganz, Tonnis or Dial osteotomies
(5) Chiari is a salvage osteotomy
Preoperative evaluation consists of anaesthetic assessment and radiological evaluation for operative planning.
Special considerations and problems should be anticipated in cases of
(1) Renal transplantation, avoid inadvertent compression of the renal transplant
(2) Diabetes - 6.5% infection with high myocardial infarction rate
(3) Gaucher's disease - high rate of loosening
(4) Cerebral palsy - high rate of dislocations
(5) Haematological problems like Sickle cell disease, Thalassemia and haemophilia
(6) Psoriasis - deep infection rate of 5.5%
(7) Lupus erythematosus, AVN due to steroids - high rate of deep infection
(8) Juvenile rheumatoid arthritis - extremely high rate of loosening
(9) Femoral neck fractures -exceedingly high failure rates after total hip arthroplasty as a primary procedure. Results of secondary replacements were found to be as good as those for primary total hip arthroplasty following displaced femoral neck fracture
(10) Developmental hip dysplasias faced with technical difficulty and high rates of failures
Surgical Procedure (Preoperative planning and prosthetic selection)
(1) Antibiotic prophylaxis
(2) DVT prophylaxis
(3) Surgical approach
(4) Acetabular preparation and version
(5) Femoral preparation and version
(6) Cement technique
(7) Post operative care
Complications:
(1) Intraoperative complications
(2) Heterotopic ossification: Significant risk factors for HO Previous HO Male sex Hypertrophic osteoarthritis Ankylosing spondylitis Advanced age
Posterior approach has lower rate of HO.
Brooker's classification of HO:
Class I - Isolated islands of bone
Class II - Gap between the bones at least 1cm
Class III - Gap between the bones less than 1 cm and
Class IV - apparent ankylosis
(3) DVT
(4) Instability
(5) Neurovascular injury
(6) Femoral fractures
(7) Loosening - Gruen zones of the femoral stem 1 to 7 : Zone 1 is on the greater trochanter and zone 7 is on the calcar. Delee's 3 zones of the acetabulum.
Acetabular deficiencies in total hip arthroplasties:
Type I - Segmental deficiencies
(a) Peripheral - superior anterior posterior
(b) Central (med. wall absent)
Type II - Cavitary deficiencies
(a) Peripheral - superior anterior posterior
(b) Central (medial wall intact)
Type III - Combined
Type IV - Pelvic discontinuity
Type V - Arthrodesis
Classification of femoral deficiencies:
Type I - Segmental deficiency
(a) proximal- can be partial or complete
(b) intercalary
(c) greater trochanteric
Type II - Cavitary deficiency can be cancellous, cortical, ectasia
Type III - Combined
Type IV - Malalignment can be rotational or angular
Type V - Femoral stenosis
Type VI - Femoral discontinuity
Vascular Anatomy:
Blood supply is by superior and inferior branches of lateral and medial geniculate arteries.
20 to 30% of the periphery of each meniscus is vascular. Rest of the meniscus gets nourishment from the synovial fluid.
Diagnosis:
(1) Twisting Injury
(2) Late appearance of effusion
(3) History of locking
(4) McMurray and Apley's Test
Meniscal lesion on the MRI scan is classified by Stoller as:
Grade I - Intra substance meniscal tear. Not communicating with the joint surface or the capsule.
Grade II - Linear intra substance tear involving the capsular periphery and
Grade III Involving the articular surface of the meniscus.
Factors Affecting Treatment
(1) Age
(2) Chronicity
(3) Daily activity
(4) Location and length of tear
(5) Associated ligament injury
Types of Tear:
(1) Degenerate
(2) Horizontal
(3) Radial
(4) Oblique (flap or parrot beak)
(5) Vertical longitudinal (bucket handle)
(6) Complex
Techniques of Meniscal repair:
(1) Open
(2) All-inside Arthroscopic repair
(3) Outside-in Arthroscopic repair
(4) Inside-out Arthroscopic repair
(5) Meniscal transplant
ANTERIOR CRUCIATE LIGAMENT INJURY
ACL encounter 400 - 500N of force during walking, can increase up to 1700N during sporting activities. Loads to failure 2500N. ACL has predominantly Type I collagen.
Counterforce from Hamstring during quadriceps exercises reduces anterior tibial translation in ACL deficient as well as ACL reconstructed knees during extension. This is the principle behind, closed chain kinetic exercises.
Goals of Treatment:
(1) Increase stability and level of function
(2) Prevent progression of osteoarthritis
Diagnosis:
(1) Lachman Test, absence of firm end point
(2) X-ray and MRI
Treatment Options:
(1) Rehabilitation exercises
(2) Surgical reconstruction
a. Primary repair
b. Repair + augmentation
c. Reconstruction with autografts
d. Reconstruction using allografts (achilles)
e. Reconstruction with prosthetic materials
f. Extra articular reconstruction
Most commonly used technique is: Bone-patellar tendon-bone autograft.
Post-op rehabilitation: Most believe in full range motion exercises as soon as possible
Combined Injuries: O'Donoghue Triad is ACL rupture, medial collateral ligament and medial meniscal injury.
Treatment:
(1) Isolated MCL is treated non operatively
(2) ACL with meniscal injury treated by early repair of meniscus and ACL reconstruction
(3) ACL with MCL injury timing of the treatment is controversial. Most believe that MCL repair along with ACL reconstruction is most beneficial
INJURIES TO THE POSTERIOR CRUCIATE LIGAMENT
Humprey = Anterior
Wrisberg = Posterior are the two meniscofemoral ligaments on either side of PCL
Mechanism of Injury:
(1) Hyperflexion with or without anterior tibial force (dashboard)
(2) Hyperflexion with downward force on the thigh
(3) Hyper extension with or without varus valgus force, common cause of combined injury
Diagnosis:
(1) History
(2) Posterior Drawer Sign
(3) Posterior Tibial Sag Sign
(4) Quadriceps Active Test
(5) Posterolateral Drawer Test with foot externally rotated to 150 is suggestive of posterolateral instability
(6) Postero medial Drawer Test with the foot internally rotated to 150
(7) External rotation Recurvatum Test
(8) Reversed Pivot Shift
(9) X-ray and MRI
TREATMENT:
Goals of treatment:
(1) Stability of the joint
(2) Restore kinematics
(3) Prevent progression of OA
Isolated PCL injury reconstruction in an asymptomatic individual is controversial
Options available are open procedures or arthroscopic assisted procedures.
Grafts may be synthetic or fresh frozen achilles tendon allograft
Posterolateral Rotary Instability: Anatomically consists of -
(1) Lateral collateral ligament
(2) Popliteofibular ligament
(3) Popliteus tendon
(4) Patellofibular ligament
(5) Arcuate ligament
(6) Short lateral ligament
(7) Posterolateral joint capsule
Following Three considerations:
(1) Transection of PCL, LCL and posterolateral complex results in the greatest amount of posterior tibial translation at all knee angles.
(2) Isolated PCL does not affect external tibial rotation
(3) Transection of posterolateral complex alone results in increased external rotation of tibia at 900
(4) Transection of LCL and posterolateral complex results in increased tibial rotation in all angles, maximum at 300 of knee flexion
Patellofemoral malalignment can be due to:
(1) Bony abnormalities
(2) Soft tissue and muscle imbalance
(3) Patellar abnormalities
Patellofemoral joints reactive force is approximately half the body weight during normal walking, greater than 3 times when climbing the stairs. Lateral facet is first to make contact.
Diagnosis:
(1) Pain and instability
(2) Examination
a. Q angle: Normal about 150 in men and 150 to 200 in women
b. J Sign of patellar tracking laterally
c. Patellar Tilt Test: normally patella can be passively tilted 0 to 200, lateral tilt less than 200 indicates lateral tightness
d. Medial and lateral patellar glide test, normal glide is 1 to 2.5 quadrants at 300 knee flexion; if it is greater than 3 - abnormal
e. Abnormal tightness or laxity of the patellar
f. Fairbank Apprehension Test
(3) X-ray examination, Merchant's view is taken with knee flexed to 450, beam angled 300 from the horizontal
a. Normal Sulcus Angle: 1400 +/- 50
b. Normal congruence angle: is -6 +/- 110
c. Lateral Patellofemoral angle normally, opens laterally
d. Look for patella alta or patella baja. If distal pole of the patella lies above the Blumensaat's line it is generally an alta. Normal Insall's Ratio Index is 1.2
Outerbridge classification of Articular cartilage degeneration (Chondrosis)
Grade I - Softening and swelling of the cartilage
Grade II - Fissuring and fragmentation, areas less than 1.3cm.
Grade III - Fissuring and fibrillation, greater than 1.2cms
Grade IV - Extensive erosion down to the bone
Treatment Options:
(1) Rehabilitation VMO exercises
(2) Operative treatment
a. Lateral retinacular release, arthroscopic or open techniques. Superior lateral geniculate vessels carefully cauterised.
b. Combination of lateral release and medial capsular reefing
c. Medial re-alignment (i) Tibial tuberosity hinged medially over periosteum - Elmslie-Trillat Procedure (ii) Tibial tuberosity medial transfer - Hauser's Procedure (iii)Semitendinosus tenodesed to patella - Galeazzi (iv) Split medial transfer of patellar tendon: Roux-Goldthwait
d. Anterior re-alignment, Maquet Procedure
e. Anteromedial re-alignment of the tibial tubercle
DEGENERATIVE DISEASES OF THE KNEE
In considering osteotomies for unicompartmental knee disorders, upper tibial osteotomies for Genu Varus and distal femoral osteotomies for Genu Valgum are to be preferred.
Complications of Upper tibial osteotomies:
(1) Inadequate valgus correction
(2) Over correction
(3) Too close to the joint
(4) AVN
(5) Popliteal artery injury
(6) Compartment syndrome
(7) Peroneal nerve palsy
(8) Delayed union or non-union
Medial compartment OA's do better than lateral compartment OA with unicompartmental replacements
Indications for unicompartmental knee arthroplasty:
(1) Age less than 60 years
(2) Heavy or physically active
(3) Unicompartmental disease
(4) Pre-requisite of less than 100 of FFD and more than 900 of flexion
Approaches:
(1) Anterior approach
(2) Southern subvastus approach
(3) Lateral approach
Technique:
(1) Pre-op planning
(2) Infection and DVT prophylaxis
(3) Skin care
(4) Limb alignment
(5) Implant sizing
(6) Ligament balance
(7) Flexion extension gap
(8) Post-op rehabilitation
Complications to consider:
(1) Infection
(2) Loosening and revision surgery
(3) Periprosthetic fracture
(4) Patellar and extensor mechanism problems
Structures anterior to the ankle:
'Tom Has A Nasty Dirty P'
Tibialis anterior
Extensor Hallucis
Artery
Nerve
Extensor digitorum
Peroneus Tertius
Structure on the medial side of the ankle:
'Tall Doctors Are Never Happy'
Tibialis Posterior
Flexor Digitorum
Artery
Never
Extensor Hallucis
Ankle Approaches:
Anterior
Anterolateral
Lateral Gatellier approach
Subtalar joint approaches:
Kocker's or Ollier's
Ankle arthrodesis techniques
RAF technique
Charnley's compression arthrodesis
Blair's sliding graft technique
Calandruccio triangular compression
Techniques of Subtalar arthrodesis:
Nughton Dunn
Denisson Fulford
Lambrinudi's
Hallux Valgus is a combination of following abnormalities of big toe:
(1) Bunion
(2) Lateral deviation of proximal phalanx
(3) Metatarsus primus varus
(4) Subluxation of sesamoids
(5) Pronation of great toe
First MTP Joint Stability:
(1) Static
a. Capsule
b. Collateral ligaments
c. Sesamoid
(2) Dynamic
a. Abductor hallucis
b. Medial slip of flexor hallucis brevis
c. Two heads of adductor hallucis
Evaluation:
Normal hallux valgus angle is up to 150 and inter metatarsal angle is 90.
Some names of Surgical options:
(1) Silver Bunionectomy
(2) McBride soft tissue release
(3) Chevron
(4) Mitchell
(5) Basal osteotomy
(6) Arthrodesis
(7) Lipidus procedure
(8) Keller's procedure
(9) Akin proximal phalanx wedge osteotomy
(1) Mallet Toe: Deformity at the DIP joint. Treated by removal of distal condyles of middle phalanx
(2) Hammer Toe: Deformity at the PIP joint. Fixed deformity Duvrie's arthroplasty and if flexible Girdlestone flexor tendon transfer
(3) Claw Toe: Hyperextension of the MTP joint.
Hyperkeratotic pathology of lesser toes:
(1) Hard corn: Dorsolateral little toe
(2) Soft corn: In between toes
Bunionette or Tailor's bunion:
(1) Large lateral condyle of 5th MT
(2) Laterally deviated 5th MT. Normal IM angle between 4 & 5 is 60
(3) Plantar Callus
Intractable plantar keratosis:
(1) Discrete IPK : Surgical
(2) Diffuse IPK: Treated by orthotics