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.

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

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

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

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

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

middle phalanx-Rockwood

Transverse fracture: more stable, less shortening risk, no periosteal envelope stripping

Extension block splinting:
．for base fracture
．for p2 base, intraarticular involvement < 40 degree
．initial 60 degree flexion, then deduct 10 degree/ week
．maintain congruent reduction

Condylar fx of the head
．close: 2 k-wire, 1 transverse, 1 oblique
．open: consider lag screw

Unstable shaft fracture
．1.2 mm K-wire
．cross pinning at fracture site: highly unstable
．interfragmentary lag screw
．mini-plate

Partial articular base fracture
．extension block pinning

Author preferred treatment
．shaft: splinting for stable, crossed pinning for unstable
．dorsal base: extensive block pinning 3 weeks. ORIF with 1.3 mm lag screw for delayed treatment

approach to spinal trauma

Approach to spinal trauma patient

Assessment (concomitant injury, neurological deficit,
Concomitant injury
1．Head, chest, long bone injury
2．Chance fx: associated with hollow viscus injury

Neurological deficit
1． ASIA score (American spinal injury association)
2． Clinical assessment

Sacral sparing & spinal shock
Bulbocarvenous reflex: mark of resolution of spinal shock
Penile or urethra stimulation → contracture of anal sphincter


ASIA score
A: complete injury
B: Sensory preserved
C: Motor preserved, MP < 3
D: Motor preserved, MP > 3
E: Normal

Clinical assessment
1． Central Cord syndrome
2． Brown sequard
3． Anterior Cord
4． Conus Medullaris
5． Cauda equina

C-spine imaging
．3 views: AP, LAT, Odontoid
．5 views: 3 views + oblique
．dynamic view: flex-ext view, time consuming in acute stage, muscle spasm masked subtle instability
．unconscious patient: LAT view only

T-L imaging
．plain film, CT, MRI for soft tissue injury
．included abdominal CT scan to exclude intra-abdominal injury

Classification of T-L spine injury
．AO classification, Denis system

Denis system
．3 column theory
．Comperssion, Burst, Seat-belt type, Fx-dislocation

distal phanlanx fracture, Rockwood

Ch. 24 Fx & dislocation of the hand
Fractures in Adults, Rockwood, 6th edition

Trade-off: stiffness or instability (mal or nonunion?)

Mechanism
Axial loading
．associated injury to carpus or upper limb

Others: isolated phalangeal injury
．crushing, trapping injury: associated soft tissue damage

Fracture reduction
．Gentle maneuver instead of forceful traction
．MP joint flexion: decreased flexor tendon force

Finger immobilization: 4 weeks, than active ROM

Local anesthesia
．NO BOSMIN
．add hyanluronic acid: enhance anesthesia, less local edema
．add 1cc 10% Bicarbonate: reduce acidity of lidocaine, less pain on injection

Bone loss in finger fracture
．Open fracture, gunshot injury
．Comminution and bone loss
．Temporary external fixation(固定distal part) or spacer
．Delayed grafting with corticocancellous iliac bone graft (more stable) or
cancellous bone graft

Distal phalanx fracture
．Tuft, Shaft, and base
．base: insertion of extensor & flexor tendon
．relative stable if fracture line distal to tendon insertion

Dorsal base fracture
．avulsion fracture VS shearing fracture
．avulsion: smaller fragment, fracture line perpendicular to tensile force
．shearting: larger fragment, > 20% joint involvement, fracture line perpendicular to joint line

Tuft fracture
．most: splinting
．concomitant of nail bed injury: pinning and repair of nail matrix

Shaft fracture
．pinning in widely displaced fracture, transverse

Dorsal base fracture
．>25% joint involvement: pinning
．extension blocking technique (DIP flexion, 1st pin for extension block of proximal fragment, reduce distal fragment, 2nd pin)
．0.045 inch K-wire
．ORIF：tension band wire, most stable in cadaveric study，but hardware complication was noted in clinical application

pediatric - humeral lateral condylar fracture

Complication after close treatment for lateral conylar or supracondylar
．Supracndylar fx: intact ROM, correctable cubitus varus
．Lateral condylar fx: impaired ROM

Classification of humeral lateral condylar fx

．Pull-off mechanism
．Pull strength from LCL complex

Classification: Milch, Jakob
．Milch I: no through ossification center of capitellum, to trochlea
．Milch II: through ossification center of capitelleum, to capitellum-radio joint

Jakob classification
1.fracture, intact medial cartilage
2.disruption of medial cartilage, minimally displaced
3.rotated and displaced fragment

initial of fracture area: posterolateral cortex

soft tissue over humeral lateral condyle
．LCL complex
．ECRL
．Brachioradialis

X-ray
．Important to differential Jakob stage I & II
．True AP, true LAT, Oblique view

Definition of minimal displacement
．2 mm
．< 2mm, stable, percutaneous pinning
．> 2mm, unstable, ORIF

ORIF:
．Crossed or parallel two pinning
．Kocher's approach

Complications of nonunion
．progressive displacement → cubitus valgus → tardy ulnar nerve palsy

Complications
Biological VS technical

1．Lateral spur formation
Fracture → over dissecting during operation → displaced periosteum → new bone formation

Fishtail deformity
．Premature closure of distal humeral physis
．osteonecrosis

Nerve injury
．acute stage: radial nerve, or posterior interosseous nerve injury
．late stage: tardy ulnar nerve palsy → malunion or nonunion related cubitus valgus. Treated with anterior nerve transposition

DDH

DDH – Developmental dysplasia of hip
F：M = 5：1
intermediate risk：breech-born boys, not-at-risk girls
highest risk：positive family history, breech-born girls
most coomon：left hip, left occiput anterior position of most vertex-presenting newborn

Condition:
an unstable, subluxated or dislocated hip
malformed acetabulum

PE:
Barlow’s: dislocation
Ortolani’s: relocation
Frequency: QOD initially, then (1, 2, 3, 4 6, 9, 12)

MTOS – Fractures – ORIF for pubis symphysis diastasis

Ligamentous structure
．Sup and inf pubic ligament
．Arcuate ligament

Indication :
．Diastasis > 2.5 cm (Tile B or C)
．Pain relief and stability of anterior pelvic ring
．Tile B: intact posterior pelvic ligament
．Diastasis: associated sacrospinous and anterior sacroiliac ligament rupture

Contraindication
．Critically ill, unstable patient`
．Open fracture with contaminated wound
．Skin compromise
．Suprapubic pouch (catheter)

Pfannenstiel incision
．Slightly curved incision above pubic symphysis
．For OB/GYN surgery
．Bikini line
．Linea alba: longitudinal splitting
．Detach linea alba: if failed reduction

Fixation methods
．reconstruction plate, 2 hole each side
．4.5mm Screw direction: A – P

Complication
．Loss of fixation: physiological motion in pubic symphysis, inadequate posterior fixation
．Impotence: due to initial injury

bisphosphonate for ONFH

published in JBJS Br, Aug 09

Alendronate
有些被用來治療ONFH

progression to collapse in 4 years
80% in control group
30% in intervention group

diagnosis of ONFH
l Predisposing factor of failure of THR or resurfacing

Early stage: better outcome

Stage III (collapse)
l Statistically significant better clinical function compared with control group
l Pain, disability, walking time, standing time

humeral nailing

Humeral nail
l For diaphysis(P/3 – M/3), proximal humerus (SN)
l For pathological fracture

Design concept：
l Spiral blade：increased surface area for load distribution
Small hole for suture anchoring of rotator cuff
l Compression design
l Locking design
l Oblique design

Increased tip – screw hole distance
Avoid stress concentration induced peri-implant fracture

Right and left, antegrade or retrograde
End cap from tissue ingrowth into threads
Proximal end: 5 mm below tip of greater trochanter
Distal end: 2.5 cm above olecranon fossa

Entry point
Proximal: lateral edge of acromion
Cartilage跟bone的交界處

Autologus chondrocyte implantation = from JBJS Br

Autologous chondrocyte implantation

• Micro-fracture
• Fibrous cartilage: poor resistance to shear force

Chondrocyte

• unable to migrate due to surrounded matrix
• could not fill the defect

injury deep into subchondral bone

• Release of potential mesenchymal cell
• Generation of fibrous cartilage
  

debridement, drilling and fixation, abrasion chondroplasty, microfracture and the use of carbon fibre pads,

1994 Britberg

• Chondrocyte harvested during arthroscopy
• Culture in suitable medua
• 5M cells
• injection into defect area and cover with periosteal flap: hyaline cartilage
  

< 2 cm2 condral defect: microfracture & mosaicplasty
1 ~ 12 cm2: ACI ( autologous chondrocyte implantation)

Pre OP evaluation

• correction of malalignment : mechanical axis
• r/o cruciate ligament and meniscus injury
• evaluation of chondrocyte lesion: Arthroscopy or MRI

Technique of ACI

• Harvest: chondrocyte from no-load-bearing area, trochlear groove
• Culture: 4-6 weeks
• Preparation of recipient area: arthrotomy, debrident, exposure of normal cartilage, avoidance of bleeding into defect area (hematoma formation), avoidance in bone defect area ( > 6mm lesion)
• Implantation
• Periosteal flap (proximal tibia) or biomembrane
• Secured with fibrin glue
• Suture: impairment of surrounding tissue and blood supply

MTOS-Ch.18-Arthroplasty for ITF

ITF:

most patient: union uneventfully



Becautious

1. Pathological fx

2. Unstable or comminuted

3. Medical comorbidity

4. Severe osteopenia

5. Previous implant failure



must r/o infection nonunion in previous operation failure

1. ESR & CRP

2. Intra-OP culture or smear



Approach

1. W/O greater trochanter fracture: AL or PL approach

2. W/ greater trochanter fracutre: Trochanter osteotomy aproach



Issue 1: When to remove prosthesis

1. after surgical dislocation

• femoral shaft w/o implant is weak. and his/her hip joint is stiff. iatrogenic shaft may be occured during surgical dislocation if implant was removed


• 先切掉head? eliminate femoral shaft fracture?

Issue 2: choice of Cup

• cementless with screw sugmentation


• press-fit w/o screw fixation is not recommended

Issue 3: choice of stem

calcar replacing prosthesis

• restore length
• reduce lesser or greater tuberosity
• fixation with Wire or cable

Issue 4: preparation of femoral canal

• scleroting tract, callus, deformity: deflecting reamer or broacher → iatrogenic fracture or femora canal peforation
• high speed burr to open femoral canal, then prepare femoral canal with reamer and broacher

Issue 5: stem length in femur with previous implant fixation

• 6 cm distal to previous screw hole ( 2 fold diaphysis diameter)
• avoid stress riser from screw hole

Issue 6: cemented stem

• good choice for severe osteopenic patient
• large cement leakage: cause of late periprosthetic fracture
• Clean and curette extravasation of cement

Issue 7: greater trochanter fracture

• cable or multiple wires
• stable enough for early mobilization
• autogenous bone grafting is recommended (harvested from femoral head)
• avoid abductor muscle strengthening in first 6 weeks

2-hole VS 4-hole DHS in ITF

關於DHS
l Side plate: 2-hole & 4-hole，biomechanical study上顯示一樣的stability
l 有人報過70個case，用2-hole side plate without failure
l 受力：力量順著posteromedial cortex傳導下來，如果有large posteromedial fragment，則受力不順，兩種情況
1. screw cut-out
2. distal screw因為一個varus collapse的力量，延伸過來變成一個pull-out strength。最後造成screw-plate interface fatigue failure

以上：其實large posteromedial cortex

就代表是unstable ITF, DHS should not be used

老年人，建議使用4個洞

因為cortex比較薄，screw的working length較不夠

Nov 2005. Injury

Biomechanics: comparision

FNF:
Cannulated screw in inverted triangle pattern

FNF, Vertical type
1. locking plate
2. DCS
3. DHS
4. Three cannulated screw

Reverse oblique ITF:
w/o gap: no difference in DHS, DCS, IM nail
w/ gap: IM nail > DCS > DHS

distal humerus fx
Orthogonal plating > posterior biplating

calcaneus

surgical repair for calcaneal tuberosity fracture
1. skin (tenting, shoe problem)
2. intraarticular involvement
3. incompetant soleus-gastrocnemius complex

surgical technique


Intra-articular fracture classification
Essex-Lopresti
1. Joint depression fracture: inferior + posterior force
2. tongue fracture: inferior force
後面一大塊tilting