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