“JAAOS 2018 - Os Acromiale (JAAOS ‘18)”
“-common in blacks<div>-bilateral in 33%</div><div>-closure of physis at 25 years</div><div>-meso-acromion most common</div><div>-US can be 100% sensitive</div><div>-Treatment</div><div><img></img></div><div>-Tension banding decreases nonunion rate</div>”
Minimizing complications in Pilon Fractures
“<div>-early fixation = no increase in infx, but decrease LOS/cost<br></br></div><div>-primary fusion</div><div>-staged sequential posterior and anterior fixation</div><div>-acute shortening</div><div>-transsyndesmotic fibular plating</div><div>-upgrading (change a C-type to B-type: buttress oblique apex fracture while doing ex-fix)</div><div><br></br></div><div><div> <div> <div> <div>Summary</div> <ul> <li>Techniques for diminishing risk of soft-tissue and osseous sepsis:</li> </ul> <div>Early ““immediate”” fixation - decreases surgical time and LOS</div> <div>Staged ““delayed”” fixation</div> <div>Upgrading</div> <div>Primary arthrodesis</div> <div>Staged sequential posterior and anterior fixation</div> <div>Acute shortening</div> <div>Transsyndesmotic fibular plating</div> <ul> <li>Degree of articular reduction relates to arthrosis (but no clinical correlation</li> <li>Clinical outcome related to</li> <ul> <li>Social factors</li> <li>Medical comorbidites</li> </ul> <li>Open fractures: risk of vascular injury</li> <ul> <li>I and D, antibiotic beads, soft tissue coverage, staged bone graft</li> </ul> </ul> </div> </div></div></div>”
interbody fusions: open vs MIS
“<ul> <li>Kambin triangle: must do a facectectomy to get here.</li> <ul> <li>Borders: exiting nerve root, superior endplate of inferior vert body, traversing nerve root (articular process)</li> </ul> </ul> <div><img></img></div> <div></div> <ul> <li>MIS: less blood loss, less narcotic use, quicker ambulation, decreased LOS, less infection risk</li> <li>Open: less radiation exposure</li> <li>Equivalent: OR time, fusion rates, patient reported outcomes, complications</li></ul>”
Perc pedicle screw stabilization
<div> <div> <div> <ul> <ul> <li>Technique</li> <ul> <li>Good xray showing level endplate, SP bisecting pedicles</li> <li>Incision with lateral margin of pedicle</li> <li>Guidewire/Screw</li> <ul> <li>Startpoint: centered on lateral pedicle margin</li> <li>Trajectory: stay within laterral 2/3rds of pedicle</li> <li>Aim to be just past posterior vertebral wall</li> <li>Remove stylet, pass guide wire through trocar to anterior 1/3rd body</li> </ul> <li>Notes</li> <ul> <li>Cannulated screws have decreased pullout strength</li> <li>T-spine: TP can block trajectory so may need more medial startpoint, with more vertical trajectory</li> <li>Use of excessive rod contouring as sole method of indirect # reduction may result in screw stripping (especially w/ shallow purchase of cannulated screws) </li> </ul> <li>Reduction</li> <ul> <li>Pedicle screws at # level maximizes # reduction (Requires intact pedicles)</li> <li>3 phases of reduction: pt position, direct manip through endplate, indirect through ligamentotaxis viad distraction</li> </ul> <li>Screw types</li> <ul> <li>Monoaxial better for compression fractures to reduce anterior wedging and maintain anterior height</li> <li>Polyaxial easier for rroad passage and can achieve compression posterior for flexion distraction</li> </ul> <li>ROH at 3-4 months maintains motion</li> <li>Contraindications</li> <ul> <li>Severe comminution</li> <li>Nonintact pedicle/facet</li> <li>Inability to get startpoint/trajectory</li> </ul> <li>Outcomes: perc vs open</li> <ul> <li>Less EBL, maybe shorter OR time</li> <li>Deformity correction same</li> </ul> </ul> </ul> <div></div> <div></div> <div></div> </ul> </div> </div></div>
Cervical Laminoplasty
<div> <div> <div> <ul> <li>Summary</li> <li>Theory: Dorsal element-preserving, motion-preserving, posterior decompression via spinal canal expansion </li> <ul> <li>Originally for OPLL</li> </ul> <li>Consideration</li> <ul> <li>Cervical kyphosis is a contraindication</li> <ul> <li>Recommend lami + fusion for >15 deg kyphosis C2-C7</li> </ul> <li></li> </ul> <li>Techniques</li> <ul> <li>Unilateral open door</li> <ul> <li>Hinge on lamina-facet junction</li> </ul> <li>Bilateral double door laminoplasty</li> <ul> <li>Osteotomy at lamina-pedicle junction</li> </ul> </ul> <li>Outcuomes</li> <ul> <li>Pre-existing kyphosis >5 deg improve less</li> <li>Laminoplasty better without fusion</li> </ul> <li>Complications</li> <ul> <li>C5 palsy 6% (vs ACDF 2%)</li> <ul> <li>67% resolve by 4 months</li> <li>If severe - consider foraminotomies</li> </ul> <li>Axial neck pain</li> <ul> <li>Preserve semispinalais cervicis mm to decrease post-op neck pain</li> </ul> <li>C2-C3 stiffness from inadvertent interlaminar fusion</li> <li>Loss of lordosis</li> <ul> <li>Dissect between paraspinal mm and avoid going lateral to lateral masses</li> </ul> </ul> </ul> </div> </div></div>
Spinopelvic fixation
<div> <div> <div> <div>Summary</div> <ul> <li>SPF: powerful technique to resist flexion/cantilever forces that cause pseudarthrosis</li> <ul> <li>Fixation to pelvis provides stability anterior to pivot point which resists cantilever bending</li> </ul> <li>Adult sacrum: poor fixation: cancellous consistency, short/capacious S1 pedicles, sacral slope = shear forces vs. L5</li> <li>Options</li> <ul> <li>Iliac screws/bolts</li> <ul> <li>23/67 require ROH</li> </ul> <li>S2 Alar Iliac fixation</li> <ul> <li>Less ROH</li> <li>low profile, ability to align with rostral instrumentation, not require use of offset connectors</li> <li>long-term consequences of crossing SI joint with S2AI = unknown</li> </ul> </ul> <li>Outcomes: beneficial for:</li> <ul> <li>Patients: osteoporotic, with 3 column osteotomies, require fusion from TL junction to sacrum</li> </ul> <li>both iliac/S2AI screws fusion at LS junction</li> </ul> <div></div> </div> </div></div>
Discoid Meniscus: Classification, Investigation findings, tx
<ul> <li>Watanabe (arthroscopic classification)</li> <ul> <li>Type I - stable, complete discoid meniscus (covers the entire plateau)</li> <li>Type II - stable, partial discoid meniscus (covers up to 80% of the plateau)</li> <li>Type III - unstable, Wrisberg variant (Wrisberg is the only thing that attaches), lack of any other posterior meniscotibial attachments</li> </ul><li>Xray</li> <ul> <li>Squaring of lateral femoral condyle</li> <li>Widening of joint space</li> <li>Hypoplastic lateral tibial spine</li> </ul> <li>MRI</li> <ul> <li>Transverse meniscal diameter > 15mm</li> <li>Continuity between the anterior and posterior horns of the menisci noted on at least three consecutive 5mm thick sagittal slices</li> <li>Selective MRI no better than physical exam</li> </ul><li>Tx</li><li>meniscal rim preservation (6-8 mm) with arthroscopic saucerization</li> <li>After saucerization, assessment of meniscal stability is performed, because peripheral stabilization is necessary in patients with unstable discoid variants. Stabilization may be achieved through all-inside, inside-out, or outside-in suture repair. Stabilizing the hypermobile meniscus contributes to the ultimate goal of meniscal preservation</li> <li>In young patients a formal inside-out meniscal repair may be performed, using a posterolateral incision to protect the peroneal nerve, popliteal vessels, and tibial nerve during suture retrieval.</li></ul>
PMC injury of the knee
“<ul> <li>associated with anteromedial rotatory instability (AMRI)<br></br></li><li>components:POL, semimembranosus, OPL, capsule, PH of MM</li><li>injury: valgus and ER</li><li>P/E: AMRI (subluxation of AM plateau on femoral condyle), anterolateral drawer test, posteromedial drawer</li><li>Repair: Best for avulsion injuries (Stener lesions with MCL retracted prox to pes)<br></br></li><li>Reconstruction: of sMCL and POL</li></ul><div><div> <div> <div><img></img></div> </div></div></div>”
Shoulder Injections
“<ul> <li>Subacromial</li> <ul> <li>Pain relief with subacromial injection doing Neer’s test</li> <li>Ultrasonography – no difference in accuracy between injections into subacromial space with or without u/s </li> </ul> <li>AC</li> <ul> <li>Accuracy 39-67%</li> <li>U/S can help given oblique joint</li> <li>No difference b/t peri-arituclar vs articular injection</li> </ul> <li>GH</li> <ul> <li>Anterior more accurate than posterior</li> </ul> <li>Suprascap nerve</li> <ul> <li>Use U/S to get to suprascapular notch to avoid neurovasc injury</li> </ul> <li>Biceps injection</li> <ul> <li>False positive for inj into groove as fluid can travel into GH joint</li> <li>Inject into sheath not tendon itself</li> </ul></ul>”
Weight Bearing Shoulder: considerations
<ol> <li>Higher prevalence of shoulder pain and rotator cuff pathology in weightbearing shoulders</li> <li>Weight bearing shoulders are stronger than healthy counterparts</li> <li>Improving external rotation strength = strongest factor in reducing shoulder pain</li> <li>Common MRI findings:</li> <ol> <li>Cuff pathology</li> <li>CA ligament thickening / edema</li> <li>AC degeneration</li> </ol> <li>Patients cannot tolerate non-WB after surgery</li> <ol> <li>use double row techniques</li> <li>Leave long head of biceps if possible, otherwise tenotomize</li> </ol> <li>No data on reverse total shoulders in this population, options are total vs hemi</li> <li>Rehab is aggressive</li></ol>
Teres Minor Review
<ol> <li>Tm tears are rare</li> <li>Tm tears are NEVER seen in isolation</li> <li>Most active in higher levels of ER, but contribute minimally if IS/SS intact</li> <li>Most accurate clinical test is ER LAG</li> <ol> <li>Elbow 90, FE 20, max ER, pt must maintain</li> </ol> <li>Important functionally in massive RCT to maintain ER</li> <li>Hypertrophies when IS/SS deficient</li> <li>Integrity affects outcomes in RTSA and Lat dorsi transfer</li> <li>Site of compression QUAD space</li> <ol> <li>Lesions can be vascular or neurologic</li> </ol></ol>
Psych Factors in Shoulder Surgery
“<ol> <li>Post op pain associated with depression</li> <li>Psychological Distress affects outcomes in </li> <ol> <li>Shoulder</li> <ol> <li>TSA: Depression independent risk factor for delirium 2.3x, anemia 1.7x, infection 2.1x, alternative discharge 1.5x.</li> <li>Cuff: high subjective pain tolerance was bigger predictor of outcome in one study</li> </ol> <li>Spine</li> <li>Arthroplasty</li> <li>ACL</li> </ol> <li>Very high rates of depression and new depression in trauma 42-48%</li> <li>Surgical factors less associated with outcome than psyche</li> <li>There are many PROs that can detect depression and that are affected by psyche distress</li> <ol> <li>These are more sensitive than routine clinical evaluation</li> </ol> <li>Depression could affect compensation in USA, despite good surgery because PROs will be one factor</li></ol><div><div> <div> <div><img></img></div> </div></div></div>”
U/S as a tool…
<ul> <li>Longitudinal sinusoidal sounds waves that reflect off of soft tissue</li> <li>Piezoelectric effect</li> <ul> <li>Reflected echoes turned into electric signals</li> </ul> <li>As good as MRI for RCT, not as good for partial tears RCT/Biceps</li> <li>Good for long bone fractures</li> <li>Better in peds elbow fractures that XR</li> <ul> <li>In hands of ED doc</li> </ul> <li>Knee</li> <ul> <li>ACL</li> <ul> <li>88% sens, 98% spec</li> </ul> <li>LCL/MCL = good</li> <li>2x as good as MRI in acute mensical tear </li> <ul> <li>?just detecting it</li> </ul> </ul></ul>
Throwers Shoulder
“<div>Key Points</div> <ul> <li>Injuries during late cocking/acceleration</li> <li>Acceleration: Pect Major, Lat Dorsi, Triceps and Serratus anterior; subscap does very little</li> <li>Deceleration: RC at risk</li> <li>Changes/Adaptations</li> <ul> <li>Late cocking leads to anterior capsule stretch/laxity (AIGHL) –> laxity -> Bankart</li> <li>PIGHL contracts -> GIRD -> risk of injury</li> <li>Increased humeral retroversion</li> </ul> <li>Throwing injuries</li> <ul> <li>(1)Internal impingement </li> <ul> <li>at 90/90 - posterosup RC contacts posterosup labrum - ie pinching of PL cuff</li> <li>PIGHL contracture can lead to GIRD</li> </ul> <li>(2) Internal impingement and anterior instability</li> <ul> <li>Repetitive micro trauma may lead to loose anterior capsule and AIGHL</li> <ul> <li>May lead to symptomatic shoulder instability</li> </ul> <li>Increased anterior translation can lead to anterior labral tearing</li> </ul> <li>(3) Primary anterior or MDI</li> <ul> <li>Extreme fatigue/dead arm </li> <li>As cuff fatigues, subluxation episodes occur</li> <li>Often MRI grossly normal</li> </ul> </ul> <li>Tx: sleeper’s stretch</li> <ul> <li>RC repair</li> </ul><li><div> <div> <div><img></img></div> </div></div></li></ul>”
LCL Injury
<ol> <li>LCL Function</li> <ol> <li>primary resistor to varus</li> <li>Secondary stabilizer to ER in early flexion, some IR throughout ROM</li> <li>Resists anterior translation in concert with ACL</li> </ol> <li>Isolated injuries are very RARE, generally PLC injury</li> <ol> <li>Can be treated non-op</li> </ol> <li>Types 1, 2: non-op with early mobilization</li> <li>Type 3: reconstruction</li> <ol> <li>Anatomic reconstruction most reliable method, lower failure</li> <li>Better knee scores at 2 years</li> <li>Better outcomes in MLKI after recon cf repair</li> <li>Non-op leads to quicker RTS</li> </ol> <li>Recon techniques</li> <ol> <li>Anatomic</li> <li>Isometric: BF tenodesis</li> </ol></ol>
ALL of the knee
<div> <div> <div> <div>Summary</div> <ul> <li>ALL restrains Internal Tibial Rotation</li> <li>Anterolateral complex</li> <ul> <li>ITB: sup + deep + capsulo-osseous layer</li> <li>Anterolateral capsule: coronary ligaments (meniscofem/tib)</li> <li>ALL = refers to either mid-third capsular ligament, capsulosseus layer of the ITB or combination of both</li> </ul> <li>Inv</li> <ul> <li>US sucks</li> <li>MRI: not reproducible</li> </ul> <li>Tx (no outcome data)</li> <ul> <li>Lateral extra-articular tenodesis or ALL reconstruction = decreases internal tibial rotation but can result in overconstraint of internal rotation at knee flexion angles >30 degrees </li> <li>Addition of LET to ACL reconstruction – lowers risk of post-op pivot shift </li> <li>Indications: young, active patients with pathology rotator laxity and imaging suggest of anterolateral complex injury, and in the setting of revision for failed ACL reconstruction with no additional features of failure identified </li> </ul> </ul> <div></div> <div></div> </div> </div></div>
Elbow US
<div>Summary</div>
<ul> <li>Epicondylitis: anechoic/hypoechoic, increased vascularity on dop</li> <li>UCL: see ligament and medial joint space widening as well</li> <li>Biceps: partial tear can be seen</li> <li>Injection possible</li></ul>
Elbow P/E
“<div> <div> <div> <div>Summary</div> <ul> <li>Milking maneuver</li> <ul> <li>positive test: patient experiences a subjective feeling of apprehension and instability along with medial elbow pain</li> <li>SN 87.5%, NPV 100%</li> </ul> <li>Moving valgus stress</li> <ul> <li>Pain between 120-70 deg flexion</li> <li>SN 100%, SP 75%</li> </ul> <li>Valgus Extension Overload Test:</li> <ul> <li>-patient seated, shoulder slightly FF</li> <li>-slight flexion at elbow, examiner applies valgus stress while bringing elbow into flexion; attempting to cause impingement of the medial tip of the olecranon on the medial wall of the olecranon fossa</li> <li>-positive = posteromedial pain</li> <li>-varus may decrease pain</li> </ul> <li>Posterolateral rotatory instability</li> <ul> <li>Lateral pivot shift</li> <li>Chair push up</li> <li>Prone push up</li> <ul> <li>Prone and chair push up more sensitive than lateral pivot shift</li> </ul> <li>Table-top relocation</li> <li>Posterolateral rotatory drawer</li> </ul> </ul> <div>-elbow flexed to 40 degrees, a-p force on lateral aspect of proximal radius and ulna applied</div> <div>-looking for translation of forearm away from humerus on lateral side, pivoting about intact medial side</div> <div>-positive = apprehension, skin dimple</div> <ul> <li>Proximal median nerve entrapment (pronator syndrome)</li> <ul> <li>Loss of pinch, fine motor skills</li> <li>differentiate from carpal tunnel: PS = numbness/paresthesias in palmar cutaneous branch of median nerve and absence of positive provocative maneuvers at the wrist</li> </ul> <li>Radial tunnel/Supinator syndrome</li> <ul> <li>Weakness and decreased sensation in SRN</li> </ul> </ul> <div></div> <div><img></img></div> </div> </div></div>”
Glenoid Rim Reconstruction
<ul> <li>Glenoid and humeral bone lesions are increasingly recognized as key risk factors in recurrent anterior glenohumeral instability - they affect the concavity-compression mechanism</li> <li>Bone defects of 20-30% of glenoid fossa --> decrease GH stability</li> <li>Glenoid on-track: when the humeral head defect is confined within the margins of the glenoid contact area in abd/ER</li> <li>CT best for estimation of defect size</li> <li>Tx: if bone loss>10% and patient RFs: do bony reconstruction</li> <ul> <li>Laterjet: Increased stability from: increased A-P diameter, dynamic sling of conjoint tendon, capsular reinforcement with coracoacromial ligament remnant </li> <li>The congruent- arc Latarjert can improve articular surface restoration </li> <ul> <li>Do not oversize graft - it will just resorb</li> </ul> <li>Iliac crest grafts can be used in arthroscopic and subscapularis-sparing procedures(go through rotator interval)</li> <li>Implant-free techniques, such as the J-bone procedure, have shown accurate graft remodeling and good clinical outcomes </li> <li>Osteochondral allografts (lateral tibial plafond) aim to restore the cartilaginous surface without the morbidity that can result from graft harvesting, but concerns remain regarding availability, contamination, and viability </li> <ul> <li>Do not resorb</li> </ul> </ul></ul>
Periprosthetic tibia fractures
<div> <div> <div> <div>Summary</div> <ul> <li>XR: # pattern, stability, bone stock</li> <li>Aspirate: cell count <1100 not reliable in # setting</li> <li>Tx</li> <ul> <li>Non-op for stable and well aligned, Cast X 6 weeks</li> <li>Locking plates</li> <li>Nail (<9mm diameter)</li> <li>Revision if unstable</li> </ul> </ul> </div> </div></div>
Bearing Surfaces in THA
<div> <div> <div> <div>Key points:</div> <ul> <li>Harder bearings have lower wear rates due to lower surface roughness and less vulnerability to deforming forces</li> <li>Lubrication is useful as it disperses pressure</li> <ul> <li>Lubrication factor: Ceramic on ceramic > metal on metal > hard on soft</li> </ul> <li>Implant factors leading to wear</li> <ul> <li>Position: Vertical cup (edge loading)</li> <li>Material: large CoCr heads (>32) with poly have high wear rates</li> <li>Time: wear rates highest in first 1 million cycles</li> <ul> <li>Osteolysis from polyethylene debris is </li> <ul> <li>0.1mm/year for linear wear</li> <li>80mm3/year for volumetric wear</li> </ul> </ul> </ul> <li>Adverse local tissue reactions</li> <ul> <li>Common with metal on metal bearings but also due to fretting and corrosion at junction of trunion and head</li> <li>RFs for local tissue reaction</li> <ul> <li>Large femoral head</li> <li>Long trunnion length, small diameter</li> <li>Long neck length</li> <li>High taper angle</li> <li>Low rigidity</li> <li>Dissimilar alloys</li> <li>Note: trunnion corrosion is lowest with ceramic heads</li> </ul> </ul> <li>XLP</li> <ul> <li>Undergoes two processes to decrease free radical (+ vitE may help):</li> <ul> <li>High dose radiation in inert gas or vacuum</li> <li>Annealing or re-melting</li> <ul> <li>Melting --> removes all free radicals but affects crystalline structures</li> <li>Annealing --> heat to just below melting point</li> <ul> <li>Removes most free radicals, no effect to overall structure</li> </ul> </ul> </ul> <li>XLP has LOWER WEAR, SMALLER DEBRIS, but is more brittle</li> </ul> <li>All Zirconia ceramic bearings taken off market for late phase transformation </li> <ul> <li>tetragonal to monoclinical transformation</li> </ul> </ul> </div> </div></div>
Young Adult Hip
<div> <div> <ul><li>Patients with structural hip abnormalities may undergo premature hip joint degeneration. However, although the relative risk of joint degeneration in patients with camtype FAI or hip dysplasia is elevated, the absolute risk is still relatively low</li> <li>FAI</li> <ul> <li>CAM lesions lead to an increased risk of developing hip OA over time, but many hips with FAI morphology will never develop OA</li> <li>Pincer: unclear</li> <ul> <li>one study suggesting that acetabular overcoverage may protect against the development of OA</li> </ul> <li>CAM</li> <ul> <li>Modified Dunn View</li> <ul> <li>Alpha angle > 55 deg</li> <li>femoral head/neck ratio < 0.17</li> </ul> <li>AP Pelvis</li> <ul> <li>The triangular index is a measure of the pistol-grip deformity on the AP pelvis radiograph that quantifies the degree in which the lateral cortex of the femoral head/neck junction diverges from the best-fit circle of the femoral head</li> <li>A value of >1 is indicative of cam-type FAI morphology </li> </ul> </ul> <li>Pincer</li> <ul> <li>Can be focal (Anterosup) or global</li> <li>X-rays: </li> <ul> <li>lateral and anterior center edge angles > 40 deg</li> <li>downsloping or negative acetabular index</li> <li>the presence of a crossover sign or acetabular protrusio/profundal or by presence of global acetabular retroversion</li> </ul> </ul> </ul> <li>Acetabular dysplasia</li> <ul> <li>Anterolateral uncoverage leads to transmission of hip forces through smaller surface aread of weight-bearing cartilage/labrum</li> <li>Deformity: coxa valga, anterveted femoral neck, lateralized hip COR</li> <ul> <li>Can lead to hypertrophied labrum and stabilizing muscles</li> </ul> <li>X-ray:</li> <ul> <li>Lateral CEA < 20 – dysplastic</li> <li>Anterior CEA (on false profile view) < 20 deg – dysplastic</li> <li>Tonnis > 10 – abnormal</li> </ul> <li>Strong evidence supports an increased risk of developing hip OA associated with acetabular dysplasia. </li> <li>Although dysplasia is commonly defined by an LCEA of <20°, the relative risk of developing OA extends into the 25°to 30°LCEA range.</li> </ul> <li>SCFE</li> <ul> <li>Cam-type deformity from anterior metaphyseal prominence</li> <li>Severity related to initial slip</li> <li>The alpha angle (or the severity of residual proximal femoral deformity) was strongly correlated with OA development and poor outcomes</li> </ul> <li>Perthes</li> <ul> <li>Coxa magna, vara, plana and secondary acetabular dysplasia/retroversion</li> <li>Severity of deformity correlated with OA</li> </ul> <li>Surgical Interventions</li> <ul> <li>For now, no evidence exists that any of these procedures are preserving the hip joint, but uncontrolled series of patients show improved pain and function at short- to mid-term follow-up. </li> <li>Surgical Indications: symptomatic disease, </li> <ul> <li>no indication for prophylactic surgery in the asymptomatic hip with structural deformity at present</li> </ul> </ul> </ul> </div> </div>
Flexor Tendon Injuries
<ol> <li>Repair strength depends on number of core sutures, more is better, 2 is not enough. </li> </ol>
<ul> <li>Authors use a 4 core cross-locked cruciate, 8 core = least risk of gapping</li> </ul>
<li>Epitendinous repair increases strength 10-50% and reduces gapping</li>
<li>Partial tears <50% can be trimmed and left alone, > 50 % require repair</li>
<li>A2/A4 pulleys can be released 25%</li>
<li>ZONE 1 </li>
<div>Acute injuries (< 6 weeks)</div>
<div>> 1cm stump = primary repair</div>
<div>< 1cm stump = pullout button or anchor</div>
<div>Chronic injuries (> 6 weeks)</div>
<div>Non-op</div>
<div>if become symptomatic = dip arthrodesis</div>
<ol> <li>ZONE 2 </li> </ol>
<div>Repair acutely or plan for 2 stage procedure</div>
<ol> <li>ZONE 3-5 </li> </ol>
<div>Direct repair acutely</div>
<div>Release Carpal Tunnel in Zone 4 injuries</div>
<ol> <li>Get patients flexing fingers early to maximize tendon excursion</li> </ol>
<div>Modified Duran protocol</div>
<div>Place-and-hold exercises. Splint with extension block</div>
<div>Kleinert protocol</div>
Thumb arthritis
<div> <div> <div> <ul><li>Anatomy</li> <ul> <li>Volar oblique (deep anterior) beak ligament becomes taut with abduction, pronation, extension (this is reduction maneuver for bennett fracture)</li> <ul> <li>New studies dispute the theory that beak ligament degeneration contributed to disease progression</li> </ul> <li>Dorsal ligaments are robust, whereas volar ligaments are weak and have minimally regular struction</li> </ul> <li>Pathoanatomy</li> <ul> <li>Thumb metacarpal pulled into adduction with MCP hyperextension</li> <li>Volar-ulnar quadrant of trapezium has greatest compressive load</li> </ul> <li>Epi</li> <ul> <li>6F:1M (ligamentous laxity)</li> <li>Labourers with repetitive thumb use</li> </ul> <li>Dx</li> <ul> <li>Grind test</li> <li>Ix: robert view</li> <li>Classification</li> <ul> <li>Eaton</li> <li>Ladd</li> </ul> </ul> <li>Tx</li> <ul> <li>Non-op</li> <li>Early OA: MC extension osteotomy, debridement, hemitrapeziectomy</li> <li>Late: trapeziectomy with sling (FCR, hematoma, suture)</li> <li>Severe Instability or young: fuse</li> <li>Lrti>fusion for females>40 years</li> </ul> </ul> </div> </div></div>
- Key Points
- Preaxial (radial-sided), postaxial (ulnar-sided) and central
- Postaxial most common
- Type B without bony connection more common than Type A with bony connection
- African Americans have higher incidence, bilateral in 70%, autosomal dominant inheritance, usually no other syndromes
- Holt-Oram syndrome (1/100,000 births, cardiac + hand anomalies)
- Fanconi anemia (1/300,000 birthda, bone marrow failure)
- Rubinstein-Taybi syndrome (1/125,000, growth delay dysmorphic facies, intellectual disability)
- If in non-African Americans, usually unilateral and can have associated syndromes
- Surgical excision is preferred
- Include traction neurectomy
- Preaxial (=thumb)
- Wassel classification (depends on bifid vs duplication and level)
- Most common is duplicated proximal and distal phalanges
- Surgical options: combination, excision-reconstruction (most common - see image) or on-top plasty
- Goals: stable joints, on-axis pull of tendons, avoid stiffness, prevent nail deformity
- Cut radial neurovascular bundles on traction to prevent neuroma
- Flexor/extensor tendons of excised thumb can either by cut or transferred to retained thumb to balance off-axis pull
- If duplication at MCP/proximal, preserve APL and transfer
- Central is most rare, often associated with syndactyly
- Requires creative surgical approach
- Should consult genetics
- 14% of SCI are tetraplegic, and only 14% undergo UE surgery
- SCI patients want:
- upper extremity function (75%)
- bowel and bladder use (13%)
- chose sexual function (3%)
- ICSHT Class
- Surgical candidates have an injury at one of the cervical spine levels (C5-8) and should have an ICSHT class 1 or better
- Elbow reconstruction (75% lose extension)
- Posterior deltoid to triceps
- Biceps to triceps (more powerful)
- Pre-req: intact brachialis/supinator to maintain flexion/supination post-op
- Hand recon
- Pre-req: active wrist extension
- Progression
- Wrist extension: BR to ECRB
- Active pinch: BR to FPL
- Thumb extension with wrist flexion: EPL tenodesis
- Etc…
- Outcomes
- Patients report that surgeries do not always improve independence but do provide increased spontaneity, speed, and ease of picking up objects and other specific tasks
- Functional electrical stimulation
- FES stimulates the lower motor neurons that are not injured
- Candidates are usually patients with spinal cord injuries at the C5-6 level with no use of the hands and wrists and few options for surgical intervention (ie, ICSHT zero and 1)
- RF: DM, CKD, EtOH, IVDU, immunocomp (82%), steroids, DMARDs, RA
- Young patients: consider gonorrhea, chlamydia, syphilis, Reiter disease, Lyme disease
- Older patients: consider gout, pseudogout, cellulitis
- Labs
- Only 58% of people with UE septic arthritis have elevated WBC (Mehta et al)
- ESR, CRP also elevated in gout, pseudogout
- Aspirate: no definitive numbers, maybe >50000cells/mm3
- PCR for lyme disease/gonorrhea
- Organisms: staph aureus, strep, pseudomonas, no organism (40%)
- MR can help for fluid collections, edema, involvement of RC, midcarpal, DRUJ
- Tx
- Surgical I and D: open or arthroscopic
- Needle aspiration: not inferior to surgical, but only used when contraindications to OR
- antibiotics
- Outcomes: generally good
- Determine previous OR technique and what was done with ulnar nerve (decompressed or transposed)
- Reasons for revision: pain, stiffness, ulnar nerve, decrease performance
- U/S may be more useful than MRI (less artifact)
- Tx: non-op for weeks then gradual return to throwing
- Surgery
- Graft options: CL palmaris, CL gracilis, autograft
- Assess tunnels for bone loss or fracture
- May need to use cortical button technique if ulnar bone loss
- Outcomes worse than primary
- Os Acromiale is failure of fusion at acromial apophysis - more common in Blacks and bilateral 33% of time.
- 4 ossification centres which fuse from posterior to anterior with 3 resultant possible patterns of os acromiale. Mesoacromion most common.
- Unstable Os Acromiale should always be in the DDx for
- Younger pts who present with
- Atraumatic Full Thickness RTC Tear or a
- High-Grade Bursal-sided RTC Tear
- Important to determine true os acromiale from normal unfused apophysis in young patients ~ ≤25 yrs
- Most cases are asymptomatic and found incidentally. Only those cases that are unstable and symptomatic require treatment.
- Initial nonsurgical management for all consisting of PT, NSAIDs, consideration of injections
- Surgical management is controversial with no clear consensus. Considerations for determining surgical technique are size and stability of os acromiale as well as patient factors. Address associated RTC pathology at same time.
- What to Remember from this article:
- Management of symptomatic and unstable Os Acromiale is controversial but here's a summary anyway…
- Initial
- Nonsurgical for all
- NSAIDs & PT & Injections
Stable- Arthroscopic Acromioplasty
- Careful to avoid destabilizing
Unstable + SmallorLarge in Lower Demand Pt- Arthroscopic Partial Excision
- Leave superior cortical shell intact
- Arthroscopic Complete Excision
Unstable + Large- ORIF (favoured technique below in bold)
- Transacromial Approach (less nonunion than deltoid take down)
- Cannulated Screws + Tension Band Stitch
- Preserve anterior vascularity + ACJ capsule
- (acromial branch of thoracoacromial artery)
- Arthroscopic Partial vs Complete Excision
RTC Pathology- Address at same time as Os
- Dislocations range from 1.5%-31%.
- Improve stability with
- Appropriate position: humerus 0-30 deg retroverted, glenoid <10 deg retroverted
- Humeral lateralization (reduces impingement but increases deltoid forces)
- 15mm of medialization can be dealt with by changing glenosphere (upsizing)
- Humeral distalization (but tensions deltoid)
- Shortening >15mm is indication for revision
- Increase constraint (but increases impingement)
- Neck shaft: 135 vs 155 - 155 has more notching
- No recommendation on glenoid size, but upsizing might increase stability.
- Placing glenoid eccentrically (inferiorly) increases stability by 17% and adduction by 11-39 degrees.
- Limited evidence to inferiorly tilt the component too.
- Complete Arthroscopic Management (CAM) is a treatment option within the algorithm
- Indications - young (<50), active, symptomatic GHOA who have failed non-op with concentric GH and retained joint space on x-ray
- Advantages - joint preserving, does not preclude future surgeries by distorting anatomy, delays or prevents arthroplasty
- Goal - address specific mechanical pathologies to restore function and relieve symptoms
- Outcomes - improvements in patient-reported outcomes and ROM but criticisms of literature are many: Level IV, small series, short-term outcomes, ?placebo effect, ?natural history
- What to Remember from this article:
- Arthroscopic management of GH arthritis is directed at addressing specific pathologies within shoulder thought to contribute to symptoms (Table 3)
- Can think through this by listing individual potential pain generators within the shoulder and how you'd address them through the scope
- Biologic glenoid resurfacing is not an effective procedure.
- Conversion from GH debridement to TSA at 5 years is 25%
- Joint: synovial joint with articular cartilage and capsule
- Types 1,2,3 = non-op
- Types 4,6 likely operative
- Types 5 = operative if >2cm displacement above acromion and fail non-op
- However, -a study showed that 77% of patients were able to return to work with nonop management
- Can treat non-op if dynamically STABLE
- ACJ fixation = hook plate
- Anatomic reconstruction (autograft>allograft)
- May need distal clavicle excision (<7mm) for reduction
- Tunnels
- Conoid is 20-25% of clavicular length from lateral clavicle
- Trapezoid in 1.5-2cm lateral to that
- OR complications
- Outcomes
- Summary
- Early fracture stabilization decreases soft-tissue damage and improve the inflammatory response
- Factors that affect local inflammation
- Soft tissue injury
- Fracture hematoma
- Stability of # management
- Systemic factors that influence local response to injury
- Acute disease states: polytrauma, sepsis
- Chronic disease states: DM,endocrine/metabolic dz, inflammatory arthropathies
- Drugs: Anti-flamm
- Fracture union influenced by surrounding muscle and a clean wound bed
- 95-100% success rate for flaps for open/mangled fractures if cleaned
- Skeletal muscle provides osteoprogenitor cells
- Muscle exposed to BMP show osteoblastic differentiation
- 4 known muscle/bone factors likely involved in the inflammatory phase of fracture healing
- 'MIBO'
- Myostatin
- IGF-1
- BMP
- Osteonection
- Acute systemic inflammation, such as in patients with polytrauma, requires an interdisciplinary approach and interdisciplinary care to enhance the hemostasis of the inflammatory response
- Chronic systemica inflamm affects # healing
- RA
- DM, RFs:
- presence of peripheral neuropathy
- Surgery duration- every additional 10 minutes past a set time increases bone healing risk incrementally by 15%
- HbA1C>7%
- RFs for non-union in distal femur fractures (Rodriguez, 2014)
- Obesity
- Open #
- Infection
- Stainless Steel Plates
- No: smoking, DM, chronic steroids
- RFs for revision surgery for tibial non-union (Bhandari, 2003)
- Open #
- Transverse #
- Fracture gap
- No: smoking, DM, chronic steroids
- NSAIDs
- Indomethacin - only drug to truly delay fracture healing (Chen, 2013)
- Indomethacin seems to be worse for diaphyseal fractures
- Metaphysis has greater progenitor/stem cells
- Avoid in patients with risk of cerebral hemorrhage or soft-tissue bleeding
- Based on the FRAX score, Treat medically if >3% risk of hip # or 20% of other fragility #
- Change in Trabeculae
- Increased intertrabecular distance
- Less connectivity between trabeculae
- More rod like than plate like
- All change screw pull out strength
- Construct considerations
- Locking fixation, far cortical locking screws (allow micromotion at fracture site with still being a stiff construct)
- Bone graft
- Cement - PMMA, CaPO4 better pullout strength than CaSO4
- Hydroxyapatite
- Spinal compression fractures
- AAOS does not recommend vertebroplasty, kyphoplasty IS an option
- See technique to improve pedicle screw pull out -->
- Use a cortical screw over pedicle screw, more medial start point, caudal to cranial medial to lateral gets cortical bite
- Augment with cement
- Longer construct
- Anterior and posterior fixation
- X-rays
- Plain x-rays are still standard for initial imaging and orthopaedic surgeons should be able to convert 2D images into 3D mental conception of fracture
- You don't have a CT scan in the OR
- Roof arc angles: Cutoff for stability is >45 degrees on each view
- EUA for PW 20-50%
- Both ilioischial and iliopectineal lines disrupted: can be transverse + posterior wall, transverse, ABC, anterior column posterior-hemitransverse or T-type (not just ABC!)
- CT
- Med to lat lines: column #
- A to P: transverse, t-type or transverse PW
- Can help determine ABC (not all ABC have classic spur sign)
- Axial: Subchondral arc - 10mm is stable (typically 5 cuts)
- Sagital: Determinine posterior column fractures that can be managed percutaneously
- Shortening (>14mm) leads to scapular dyskinesis
- COTS Study
- ORIF patients had better outcome scores, a shorter time to union (16.4 versus 28.4 weeks), lower rates of nonunion (3% versus 14.2%), and lower rates of malunion.
- defined a displaced clavicle fracture as one that had no cortical contact between the fracture fragments
- Radiographic Parameters considered Relative Indications for Surgery
- Displacement >100% - most important
- Shortening >2cm
- Z-type Pattern - displaced rotated butterfly fragment interposed
- Significant comminution
- RFs for symptomatic non-union
- Lack of cortical apposition
- Female sex
- Comminution
- Advanced age
- Smoking
- Non-op and post-op protocol: no overhead until 6 weeks, no WB til 3 months, RTS at 4-6/12
- Surgical
- 2.7 LCP has lower ROH than 2.5
- 2.7 recon has higher implant failure, malunion, nonunion
- Plate Position - Superior vs Ant-Inf - both have similar results
- Dual Plating - early results show less HW irritation and superior biomechanical strength compared to single plating
- Female or Skinny Pt - consider precontoured or dual plating
- IMN - often requred open reduction anyways (75%), second surgery required as all must be removed at ~6 months
- Plate biomech stronger than nail
- Hemi vs THA
- vs THA, hemi has; reduced surgical time, less blood loss, decreased risk of instability, fewer postop complications
- but THA; better pain relief, lower long term reoperation rates
- THA for fracture has higher complication rate than elective THA
- Cemented hemi
- Article states equivalent to uncemented (although registry data would disagree)
- Use cement in osteoporosis bone
- Mortality
- Decreased 30 day mortality if OR <12-24 hours
- 30 day mortality if
- infected: 20%
- Dislocated: 10%
- Note do a THA if CEA<40 (ie dysplastic)
- Hemi complications: 12%
- Loosening, fracture (press fit>cemented), malposition, infection
- Acetabular erosion - longer time to presentation
- Hemi to THA
- Complications 12%
- 29% 1 year mortality
- IM sclerosis leads to eccentric reaming - address this!
- Get good reduction with schanz pins, open reduction with clamp
- Pedestal
- Sharp awl
- Stiff reamer
- Open approach with burr
- Compress!
- Do not want >2mm distraction
- Plate if canal to small to accommodate nail
- Blade plate
- PF locking plate
- Biologic augmentation
- Little evidence for BMP, bone grafting
- Post-op
- Endocrine consult
- Stop bisphosphonates
- Vit D - correct to a minimum of 30ng/mL
- Calcium - 1000-1200mg/d
- Teriparatide
- Outcomes
- Do not treat non-op
- Union 7months in 80%
- Complications
- Fracture propagations: avoid by overreaming 2mm
- Concomitant ipsilateral femoral neck fractures occur in 2-9% of all fem shaft #s
- Paramount importance to identify ipsilateral neck #s - missed diagnosis rate of 6-22%
- Neck fracture: basicervical, vertically oriented, nondisplaced 60%
- Knee injury 20-40%, hip dislocation
- Adequate pre-operative and intra-operative imaging of femoral necks in all femoral shaft fractures can prevent the consequences of a missed neck #
- Complications
- Fem neck: nonunion/malunion (5%, lower than if isolated), AVN
- Shaft: nonunion (20%) - higher energy, open
- No consensus exists regarding optimal treatment wrt:
- Order - neck vs shaft first
- Method - single vs dual construct
- Consider prophylactic neck fixation in all fem shaft #s
- Incidence of knee pain: 0-10% severe, 35-35% some
- Incidence is decreasing with techniques and implant selection
- Higher incidence with tibial nonunion
- Quads weakness correlated with knee pain
- Lower rate with semi extended
- Knee pain etiology
- Menisci 30% rate of 'near-meniscal' injury
- ACL
- Cartilage 20%
- Safe zone: 9mm lateral to midline and 3mm lateral to tibial tubercle
- Supra-patellar
- May have less knee pain
- Less injury to infrapatellar branch of saphenous nerve
- 30% have PF damage on scopes post-op
- Management
- ROH - 50-95% relief, 25% partial relief, 20% no difference
- RIA properties: ALL 3!
- Osteoinductive (BMP): stimulates bone growth and induction ofstem cells
- Osteoconductive (DBM): structural framework
- Osteogenic: directly provides cells that produce bone (MSC, osteoblasts, osteocytes)
- RIA vs IC-BG
- All biochemical markers seem superior in RIA compared to iliac crest
- RCT: RIA has more graft and less morbidity
- ICBG complications
- Minor 2-39% (19%): infection, hematoma, seroma, pain, scar sensitivity, meralgia paresthetica
- Major 0-18%: pseudoaneurysm, AV fistula, pelvic instability, avulsion of ASIS, hernia
- RIA complications
- Low rate complications, largest series RIA 1.96% major complication rate = 3 donor site # and 1 intra-op perf.
- SER 4 - includes either MM# or deltoid injury (bimal equivalent)
- Anatomy
- Superficial - primary restraint to eversion
- TN, TC, TT
- Deep - primary restraint to ER
- ATTL, PTTL
- 1mm of deviation of talus = 40% reduction in TT contact pressures
- Ruptures
- From medial mal (not intra-substance or talus)
- Mortise: valgus tilt = deep and sup rupture
- >4mm clear space
- >1mm than superior TT distance
- MR: not useful
- Intra-op
- Test after fibula fixed
- Positive ER stress >4mm, >1mm
- Positive valgus/eversion stress with >7 deg talar tilt
- Tx
- Suture anchor
- Outcomes
- Unclear clinical
- Better radiographic signs of instability
- Metal on metal > ceramic on ceramic > metal on poly > ceramic on poly
- Ceramic on poly > metal on poly > metal on metal > ceramic on ceramic
- Ceramic on ceramic > ceramic on poly > metal on metal > metal on poly
- Ceramic on ceramic > metal on metal > metal on poly > ceramic on poly
- Large femoral head
- Small trunnion diameter
- Long trunnion length
- High taper angle
- Long neck length
- Low rigidity
- Dissimilar metals
- They are softer than alumina
- They undergo monoclinical phase transformation
- They are the most common type of ceramic surface on the market
- They never fracture
- Decreased head offset
- Increased anteversion
- Larger acetabular hemisphere
- Use of offset liners
- 3 or more dislocations
- CNS disorders
- EtOH abuse
- Cognitive impairment
- Abductor deficiency
- Revision procedures
- Both articulations move at the same time
- The larger articulation moves first until it impinges, followed by the smaller articulation
- The smaller articulation moves first until it impinges, followed by the larger articulation
- All dual mobility constructs must utilize a locking ring
- Pincer type FAI
- Cam type FAI
- Ischiofemoral impingement
- Subspine impingement syndrome
- Alpha angle > 55 degrees
- Head-neck offset ratio < 0.17
- Triangular index > 1
- Gunstock deformity
- Open Treatment
- Age >10
- Fracture location / Delbet classification
- Initial fracture displacement
- Highest contribution at age 2-4 months
- Contribution in early adulthood less than in adolescence
- Contribution in early adulthood increases from adolescence
- Lowest at birth
- Ligamentum Teres
- Medial Femoral circumflex
- Posterosuperior branch of lateral femoral circumflex
- Anterolateral branch of obturator artery
-
Tumor75
-
Tumor - RC Q's92
-
Trauma - RC Q's176
-
Trauma118
-
Sports - RC Q's55
-
Sports28
-
Spine - RC Q's117
-
Spine83
-
Shoulder - RC Q's80
-
Shoulder30
-
Peds - RC Q's273
-
Peds78
-
JAAOS2018131
-
JAAOS 201853
-
H&W - RC Q's127
-
H&W68
-
F&A - RC Qs81
-
F&A44
-
FLUFF41
-
Elbow - RC Q's38
-
Elbow42
-
Diseases7
-
Basic Science91
-
ATLS7
-
Arthroplasty - RC Q's102
-
Arthroplasty85
-
2021 Exam173
-
2020 Q's2
