Bone substitute的比較
把porcine femur cancellous bone，拿去和Bone substitue混合，放入含osteogenic medial去培養，1週後用電子顯微鏡觀察存活的細胞
發現
．β-TCP: 含有最多活細胞
．再來是Calcium sulfate
．再來是DBM: demineralized bone matrix
．最差的是HA
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NSAIDs
．研究認為會抑制endochondral ossification
．但對於perimembranous ossification則較無影響
2010年1月7日 星期四
2009年10月30日 星期五
DHS的complication
同樣的小手術作久了，任何事情都可能發生..
1.Lag screw不夠深
2.entry point偏了，整個把anterior wall打爆
3.compression screw沒有鎖到底
4.impactor打太大力，整個medialization
5.
1.Lag screw不夠深
2.entry point偏了，整個把anterior wall打爆
3.compression screw沒有鎖到底
4.impactor打太大力，整個medialization
5.
2009年10月15日 星期四
Osgood Schlatter disease
Overuse, repetitive strain onto 2nd ossification center
Bone growth rate >> soft tissue growth
Young, active, male, jumping sport
13-14 y/o
P/E
Reproducible knee pain
Pain on resisted extension, pain on full flexion
25% bilateral
pain on proximal tibial tuberosity
tenderness, thickening of proximal tibia
proximal mirgration of patellar tendon insertion area
differential diagnosis
．Slidung-Larsen Johnssen Disease: calcified patellar tendon insertion
．Jumper’s knee
．Quadriceps avulsion
．Overuse syndrome
．multipartie patella
．plica syndrome
．chondromalacia patellae
X-ray
．knee lateral view with 10-20 degree internal rotation
．rule out malignancy, fracture, infection
．superficial ossicle in patellar tendon
Bone scan
．increased uptake
Management
Conservative treatment: rest, NSAIDs, Icy packing, immobilization
Prognosis
．spontaneously resolved within one year
．persisted until closure of physeal plate
Bone growth rate >> soft tissue growth
Young, active, male, jumping sport
13-14 y/o
P/E
Reproducible knee pain
Pain on resisted extension, pain on full flexion
25% bilateral
pain on proximal tibial tuberosity
tenderness, thickening of proximal tibia
proximal mirgration of patellar tendon insertion area
differential diagnosis
．Slidung-Larsen Johnssen Disease: calcified patellar tendon insertion
．Jumper’s knee
．Quadriceps avulsion
．Overuse syndrome
．multipartie patella
．plica syndrome
．chondromalacia patellae
X-ray
．knee lateral view with 10-20 degree internal rotation
．rule out malignancy, fracture, infection
．superficial ossicle in patellar tendon
Bone scan
．increased uptake
Management
Conservative treatment: rest, NSAIDs, Icy packing, immobilization
Prognosis
．spontaneously resolved within one year
．persisted until closure of physeal plate
2009年10月12日 星期一
femoroacetabular impingement
Femoroacetabular impingement
．Limited hip ROM
．Progression to OA
．classification: cam or pincer type, most common: mixed type
Cam type:
．loss of concavity of proximal femur, femoral head aspherecity
．anterosuperior aspect
．Perthe’s disease, SCFE
Pincer type：
．overcoverage of acetabular rim
．DDH, post periacetabular osteotomy
．retroverted acetabulum
PE:
．Internal rotation < 20 degree on hip flexion at 90 degree
．exclude referred pain (inject bupivacaine into hip joint)
Image for cam type
．cross table lateral view (with hip 10 degree internal rotation)
．Dunn view
．α angle
Image for pincer type
．AP view
．Cross over view (crossing of ant & post wall line), posterior wall view (femoral head center lying lateral to posterior wall), ischial sign(ischial spine projecting into pelvic cavity)
．Coxa profunda
Others:
．CT: good for bone
．MRI: acetabulum rim, labral tears, fibrocystic change
Treatment: considerations
1．Physiologic age of patient’s hip
2．Joint narrowing 1-2 mm
3．The damage of subchondral-labral-cartilage structure
4．Severity of retroverted acetabulum
5．Associated proximal femur deformity
Treatment
1．Open correction with dislocation
2．Arthroscopic debridement w/o dislocation
3．Periacetabular osteotomy
1．Oepn dislocation
．for cam type
．expose head-neck junction, acetabular rim
．most important: preserve blood supply to avoid osteonecrosis
．trochanteric osteotomy, lateral to piriformis fossa
．adverse effect: sicatic nerve neurapraxia, trochanteric nonunion
2．Periacetabular osteotomy
．for retroverted acetabulum with posterior wall sign(+)
．anterior arthrotomy + surgical dislocation
．revision：poor orientation, anterior or posterior impingement
．Limited hip ROM
．Progression to OA
．classification: cam or pincer type, most common: mixed type
Cam type:
．loss of concavity of proximal femur, femoral head aspherecity
．anterosuperior aspect
．Perthe’s disease, SCFE
Pincer type：
．overcoverage of acetabular rim
．DDH, post periacetabular osteotomy
．retroverted acetabulum
PE:
．Internal rotation < 20 degree on hip flexion at 90 degree
．exclude referred pain (inject bupivacaine into hip joint)
Image for cam type
．cross table lateral view (with hip 10 degree internal rotation)
．Dunn view
．α angle
Image for pincer type
．AP view
．Cross over view (crossing of ant & post wall line), posterior wall view (femoral head center lying lateral to posterior wall), ischial sign(ischial spine projecting into pelvic cavity)
．Coxa profunda
Others:
．CT: good for bone
．MRI: acetabulum rim, labral tears, fibrocystic change
Treatment: considerations
1．Physiologic age of patient’s hip
2．Joint narrowing 1-2 mm
3．The damage of subchondral-labral-cartilage structure
4．Severity of retroverted acetabulum
5．Associated proximal femur deformity
Treatment
1．Open correction with dislocation
2．Arthroscopic debridement w/o dislocation
3．Periacetabular osteotomy
1．Oepn dislocation
．for cam type
．expose head-neck junction, acetabular rim
．most important: preserve blood supply to avoid osteonecrosis
．trochanteric osteotomy, lateral to piriformis fossa
．adverse effect: sicatic nerve neurapraxia, trochanteric nonunion
2．Periacetabular osteotomy
．for retroverted acetabulum with posterior wall sign(+)
．anterior arthrotomy + surgical dislocation
．revision：poor orientation, anterior or posterior impingement
CMC joint, Rockwood 6th, Ch.24
CMC joint fracture dislocation: carpo-metacarpal
．high energy
．5th CMC: associated ulnar nerve injury
．3rd CMC: deep palmar archs
．shortening of Metacarpal bone
．Brewerton view: evaluate metacarpal base: 60 degree CMC joint flexion
．CT if suspected carpal bone fracture
Pure CMC dislocation
．rare
．evaluate its stability
Thumb CMC fx dislocation
．partial: Bennett’s fx, Complete: Rolando’s fx
．Thumb CMC: intermetacarpal lig, volar & post oblique lig, dorsoradial lig
．Pinning for thumb base fx:
(1) radial a
(2) superficial radial and lateral antebrachial n.
(3) extensor tendon (APL, EPB, EPL)
．Deforming force:
(1) APL: extension force in thumb metacarpal base (toward proximal & radial side)
(2) Adductor Pollicis: adduction force on thumb metacarpal head (adduction and rotation)
Non-OP Treatment
．stable, minimally displaced fx
．for displaced fx: poor satisfactory outcome,
．malrotation, varus deformity, arthritic change
Operative treatment
．CRIF: current strategy
．restore length, maintain reduction, at least 6 weeks
．ORIF: for delayed operation
Pure CMC dislocation
．reconstructed with FCR
Thumb CMC fx-dislocation
．Bennett’s > Rolando
．Step-off < 1mm, no difference in its outcome between CRIF or ORIF
．CRIF: more adduction contracture
．complex Rolando: severe comminution (complex operation for orthopaedic surgeon without subspeciality, minimal open + external fixation)
Author’s preference:
Pure thumb CMC dislocation
．immediate ligament reconstruction: not suggested
．primary capsule repair with 1.3mm bone anchor
Bennett’s fracture
．two pins: one toe trapezium, one to index metacarpal
Rolando’s
．distraction and maintaining length
．maintaining length: .062 wire fixed on 2nd metacarpal
．Plate & screw: early range of motion, adhesion to EPL, EPB may result in limitation of ROM
．Approach: Wagner’s incision (Incision → reflect thenar muscle → expose APL → arthrotomy
Complication: hypersensitivity
．small nerve fiber branch injury during trauma or operation
．neuroma formation
．Medication: Gabapentin, Amitryptyline
．high energy
．5th CMC: associated ulnar nerve injury
．3rd CMC: deep palmar archs
．shortening of Metacarpal bone
．Brewerton view: evaluate metacarpal base: 60 degree CMC joint flexion
．CT if suspected carpal bone fracture
Pure CMC dislocation
．rare
．evaluate its stability
Thumb CMC fx dislocation
．partial: Bennett’s fx, Complete: Rolando’s fx
．Thumb CMC: intermetacarpal lig, volar & post oblique lig, dorsoradial lig
．Pinning for thumb base fx:
(1) radial a
(2) superficial radial and lateral antebrachial n.
(3) extensor tendon (APL, EPB, EPL)
．Deforming force:
(1) APL: extension force in thumb metacarpal base (toward proximal & radial side)
(2) Adductor Pollicis: adduction force on thumb metacarpal head (adduction and rotation)
Non-OP Treatment
．stable, minimally displaced fx
．for displaced fx: poor satisfactory outcome,
．malrotation, varus deformity, arthritic change
Operative treatment
．CRIF: current strategy
．restore length, maintain reduction, at least 6 weeks
．ORIF: for delayed operation
Pure CMC dislocation
．reconstructed with FCR
Thumb CMC fx-dislocation
．Bennett’s > Rolando
．Step-off < 1mm, no difference in its outcome between CRIF or ORIF
．CRIF: more adduction contracture
．complex Rolando: severe comminution (complex operation for orthopaedic surgeon without subspeciality, minimal open + external fixation)
Author’s preference:
Pure thumb CMC dislocation
．immediate ligament reconstruction: not suggested
．primary capsule repair with 1.3mm bone anchor
Bennett’s fracture
．two pins: one toe trapezium, one to index metacarpal
Rolando’s
．distraction and maintaining length
．maintaining length: .062 wire fixed on 2nd metacarpal
．Plate & screw: early range of motion, adhesion to EPL, EPB may result in limitation of ROM
．Approach: Wagner’s incision (Incision → reflect thenar muscle → expose APL → arthrotomy
Complication: hypersensitivity
．small nerve fiber branch injury during trauma or operation
．neuroma formation
．Medication: Gabapentin, Amitryptyline
2009年9月30日 星期三
ABx-loaded product-from Injury
Prophylaxis and treatment of implant-related infections by local application of antibiotics
Injury 2006
Basic concepts for Implant associated infection
．Bacteria on implant: decreased metabolic activity
．Higher MIC was needed to eradicate organism when metabolic activity was decreased (Pseudomonas aeruginosa 800X if reduced metabolic activity)
．Local application, like ABx impregnated spacer, could achieve 1000x concentration or higher
These article
Prophylaxis：Cement bead, Antibacterial coating implant
Treatment：Cement bead, GM-loaded collagen sheet, ABx-loaded spacer
Initially
．GM loaded cement beads
．higher local concentration, no systemic effect, gradual release
．disadvantage: select GM resistant bacteria
．should be removed 4-6 weeks later (became foreign body)
ABx-coating implant
．Synthes
．biodegradable GM, Chlorohexidine
．reduce the rate of osteomyelitis
．pending large, clinical trials
ABx loaded collagen sheet
．PMMA beads: another operation for removal
．Collagen sheet: biodegradable
．disadvantage: short T1/2
ABx loaded spacer
．prevent soft tissue contracture, arthrofibrosis, instability
．disadvantage: expensive
Injury 2006
Basic concepts for Implant associated infection
．Bacteria on implant: decreased metabolic activity
．Higher MIC was needed to eradicate organism when metabolic activity was decreased (Pseudomonas aeruginosa 800X if reduced metabolic activity)
．Local application, like ABx impregnated spacer, could achieve 1000x concentration or higher
These article
Prophylaxis：Cement bead, Antibacterial coating implant
Treatment：Cement bead, GM-loaded collagen sheet, ABx-loaded spacer
Initially
．GM loaded cement beads
．higher local concentration, no systemic effect, gradual release
．disadvantage: select GM resistant bacteria
．should be removed 4-6 weeks later (became foreign body)
ABx-coating implant
．Synthes
．biodegradable GM, Chlorohexidine
．reduce the rate of osteomyelitis
．pending large, clinical trials
ABx loaded collagen sheet
．PMMA beads: another operation for removal
．Collagen sheet: biodegradable
．disadvantage: short T1/2
ABx loaded spacer
．prevent soft tissue contracture, arthrofibrosis, instability
．disadvantage: expensive
2009年9月24日 星期四
subtrochanteric osteotomy for Crowe IV dysplatic hip
subtrochanteric osteotomy for Crowe IV dysplatic hip - JBJS Am 2009/09
Dysplastic hip: Crowe classification, according to its degree of subluxation (dislocation)
Crowe type IV: complete dislocation
True acetabulum: Better quality for Cup support
Without shortening: difficult reduction, sciatic nerve injury
THA with subtrochanteric shortening osteotomy:
．for cementless proximal ingrowth stem
．avoid change of anatomy of proximal femur
Surgical technique
．osteotomy site: 8 – 10 cm distal to tip of greater trochanter
．transverse subtrochanteric osteotomy
．autogenous cancellous bone graft over osteotomy site
．neck cut region: 1 cm proximal to lesser trochanter
Preparation of femoral canal
．reaming + broaching
．osteotomy
．implantation of stem
．lateral coverage for cup: superolateral femoral head
．osteotomized femoral canal: as cortical strut graft, fixed with Cable wire
Dysplastic hip: Crowe classification, according to its degree of subluxation (dislocation)
Crowe type IV: complete dislocation
True acetabulum: Better quality for Cup support
Without shortening: difficult reduction, sciatic nerve injury
THA with subtrochanteric shortening osteotomy:
．for cementless proximal ingrowth stem
．avoid change of anatomy of proximal femur
Surgical technique
．osteotomy site: 8 – 10 cm distal to tip of greater trochanter
．transverse subtrochanteric osteotomy
．autogenous cancellous bone graft over osteotomy site
．neck cut region: 1 cm proximal to lesser trochanter
Preparation of femoral canal
．reaming + broaching
．osteotomy
．implantation of stem
．lateral coverage for cup: superolateral femoral head
．osteotomized femoral canal: as cortical strut graft, fixed with Cable wire
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