Lower Limb

Femur

Distal Femur Fractures

AO Classification

 

Supracondylar

 

Distal Femoral FractureSupracondylar Femur Fracture Retrograde Nail0002

 

Distal femoral fractureDistal Femur Fracture Lateral

 

Unicondylar

 

Distal Femur Fracture Medial

 

Intracondylar

 

Distal Femur Fracture

 

Distal Femur Fracture Intercondylar 1Distal Femur Fracture Intercondylar  2Distal Femur Fracture Intercondylar CT

 

Management

 

Non operative Management

 

Issue

 

Difficult

- cannot immobiise joint above

- need to keep knee stiff

 

Operative Management

 

Options

 

1.  Retrograde nail

2.  Plate

3.  Tumour prosthesis

 

1.  Retrograde Nail

 

Supracondylar Femur Fracture Retrograde Nail0001Supracondylar Femur Fracture Retrograde Nail0001

 

Advantage

- small incision

- good for floating knee

- load sharing

 

Supracondylar Femur Fracture Retrograde Nail0003Supracondylar Femur Fracture Retrograde Nail0004

 

Disadvantage

- more difficult for intra-articular fractures

- technically difficult to perfectly restore alignment

 

Indications

- distal 1/3

- floating knee

 

Technique

 

Set up

- patient supine

- put knee over radiolucent triangle / bundle of gowns

- allows entry to knee

- ensure II for AP and lateral of knee and AP of hip for proximal locking screw

 

Entry point

- medial parapatella approach

- entry above ACL origin

- slightly medial

- ensure central in AP and lateral

- awl / 3.2 mm guide wire

- ream for enlarged end of retrograde nail

 

Pass guide wire

- measure length

 

Ream & Insert nail

- distal locking performed

- proximal AP locking under II control

 

Retrograde Nail Proximal0001Retrograde Nail Proximal0002

 

Results

 

Iannacone et al J Orthop Trauma 1994

- 41 distal femur fractures treated with retrograde nail

- 4 non unions requiring revision fixation

- 4 fatigue fractures of the IMN; changed to using minimum 12 and 13 mm rods

 

Case Nonunion

 

Retrograde Nail Nonunion0003Retrograde Nail Nonunion0004Retrograde Nail Nonunion0001Retrograde Nail Nonunion0002

 

Supracondylar Nonunion TKR0001Supracondylar Nonunion TKR0002

 

2.  Plate

 

Distal Femur Fracture Medial ORIFSupracondylar Plate ORIFSupracondylar Plate Lateral

 

 

Advantage

- easier to fix intracondylar extension

- can be done MIPO / minimally invasive plate osteosynthesis

- plates anatomically contoured so can restore mechanical axis

 

Technique

 

Position

- patient supine on radiolucent table with II

- place distal femur over radiolucent triangle / drapes

- reduces fracture

 

Incision

- incision over lateral distal femoral condyle

- longitudinal

- through skin and soft tissue

- divide ITB

- elevate vastus lateralis

- down to bone

 

Reduce intra-articular portion if required

- can elevate patella to assess reduction

- compress with bone reducing forcep

- 6.5 mm cannulated screws

- anterior and posterior to plate

- ensure not in joint / above blumensaat's

- ensure not in PFJ (distal femur is trapezoidal)

 

MIPO plate technique

- percutaneously elevate muscle off femur with elevator

- insert appropriate length plate (4 cortical screws above) with targeter

- temporarily fix distal plate to distal fragment

- if place screws parallel to joint line, the plate will be in correct valgus

- temporarily fix proximal plate percutaneously with temporary fixation screws

- obtain an indirect reduction

- check aligment and plate position AP and lateral

- attach plate with screws

 

Results

 

Schutz et al Arch Orhop Traum Surg 2005

- 62 patients average age 52 years treated with LISS plate

- union achieved in 85% patients

- 6 required bone grafting, 3 required revision of components

 

Tumour Prosthesis

 

Elderly osteoporotic patient

- unreconstructable distal femur

Femoral Shaft Fractures

Epidemiology

 

Usually young patients

- 15 - 40

 

15% compound

 

Aetiology

 

High velocity injury

- MBA

- MVA

- pedestrian v car

- fall from height

 

Emergency Managment

 

EMST principles

- need for transfusion not uncommon

- hypotension from isolated closed femoral fracture unlikely

 

Beware

- ipsilateral NOF / pelvic fracture / acetabular fracture / dislocation

- knee injury

- floating knee / ipsilateral tibial fracture

 

Thorough neurovascular exam

- incidence vascular injury 1%

 

Temporary femoral traction splints

- ring against ischium

- velcro around foot

- pneumatic traction

- can only be applied for 12 hours or so

 

Thomas Splint

 

Compound wound

 

Betadine pack

Tetanus

Antibiotics

 

Winquist Classification

 

Type 1

- minimal or no comminution

 

Femoral Shaft Fracture No comminution

 

Type 2

- < 50% comminution

 

Type 3

- 50 - 100% comminution

- inherently unstable as < 50% contact between major fragments

- need supplemental fixation / must be locked

 

Femoral Fracture Type 3

 

Type 4

- segmental comminution

- no contact or inherent stability between proximal and distal fragments

 

Associated injuries

 

Femoral Shaft Fracture with Neck Fracture

 

Up to 10% concurrence

- can be missed on plan film

- splints can obscure

 

Assessment

- carefully review pelvic xrays

- order CT if required

- assess carefully on II when intra-operatively

 

Knee

 

De Campos et al 1994 Clinical Orthopedics

- 5% ACL, 2.5% PCL

- 20% LM tears, 12% MM tears

 

Always assess knee after femoral stabilisation

 

Femoral Fracture + ACL Reconstruction

 

Floating Knee

 

Ipsilateral Femur + tibial fracture

 

Floating Knee 1Floating Knee 2

 

Operative Management Issues

 

Surgical Timing

 

Bone et al JBJS Am 1989

- stabilisation within 24 hours

- decreased pulmonary complications

- decreased length hospital stay

 

Damage Control Orthopaedics

 

Concept

- avoid second hit to severely injured patients

- stabilise femoral fracture as quickly as possible

- usually simple external fixator

- allow return to ICU for warming / stabilisation

- when stable, definitive fixation

 

Indications

- head injuries

- thoraco-abdominal injuries

- multiple injuries

 

IL-6

- cytokine shown to be elevated in multitrauma

- suggested delay definitive treatment until drops

- approximately day 6

 

Results

 

Pape et al J Orthop Trauma 2002

- retrospective study of polytrauma patients at risk of multi-organ failure

- patients treated with ETC (early total care)(IMN femur) v

- DCO (early stabilisation femur external fixation with later IMN)

- significant reduction in incidence of multiorgan failure

- significant reduction ARDS (15% down to 9%)

- no increased rate of local complications (infection, non union)

 

Bhandari J Orthop Trauma 2005

- external fixator converted to IMN within 2 weeks

- 1.7% infection rate

 

Surgical Options

 

ORIF / plate

External fixation

IMN - antegrade / retrograde / reamed / unreamed

 

External Fixation

 

Indications

- severely contaminated wound

- Damage Control Orthopaedics

- complex femoral fracture with vascular injury

 

Technique

- 2 x half pins proximally

- 2 x half pins distally

- 2 x bars

 

Timing of conversion to IMN

 

Harwood et al J Orthop Trauma 2006

- compared 111 femur fractures treated with immediate IMN to 81 DCO

- DCO femurs more likely to be grade 3 compound

- increased pin site infections in external fixation

- no significant increase in deep infection rates if converted within 2 weeks

 

Plate v IMN

 

Results

 

Bosse et al JBJS Am 1997

- compared plate v reamed IM nail (117 v 104)

- patients multiply injured (femur + thoracic injury)

- no evidence that a reamed femoral IMN increased risk of ARDS in this group

 

Plate

 

Indications

- associated proximal / distal femoral fracture

- vascular injury

- medulla too narrow for IMN

- paediatric population

 

Problem

- tension side / load bearing

- significant disruption to blood supply required

- plate will break early if union not achieved

 

Results

 

Giessler et al Orthopedics 1995

- 71 femurs diaphyseal fractures

- 93% union at 16 weeks

- recommended bone grafting at same time

 

Technique

- large fragment plate

- minimum 8 cortices each side of fracture

- need periord of NWB

 

Reamed v Unreamed IMN

 

Femoral Nail0001Femoral Nail0002

 

Results

 

Non union / Canadian Study Group JBJS Am 2003

- multicentred randomised trial

- non union rates reamed v unreamed IMN

- 8 / 106 (7.5%) smaller unreamed femoral nail nonunion

- 2 / 121 (1.7%) larger reamed femoral nail nonunion

 

ARDS / Canadian Study Group J Orthop Trauma 2006

- multicentred randomised trial reamed v unreamed

- incidence ARDS in multiply injured patients

- 151 unreamed v 171 reamed nails within 24 hours

- very low incidence of ARDS in both groups

- not statistically significant

- need some 35 000 patients to detect difference

 

Locked v Unlocked IMN

 

Unusual not to lock distally

- gives rotational stability

 

If stable transverse fracture / > 50% cortical apposition

- can dynamically lock

 

Retrograde nail

 

Retrograde Femoral NailRetrograde Femoral Nail Lateral

 

Indications

- floating knee (single incision for femoral and tibial nail

- obesity - difficult access to trochanter

- pregnancy - minimise radiation to pelvis

- patella fracture (able to ORIF with same incision)

- ipsilateral pelvic / acetabular / NOF fracture

 

Outcome

- similar rates union

- may have slightly higher incidence knee pain

 

Floating Knee 1Floating Knee 2Floating Knee 3

 

NOF (Neck of Femur) + Femoral shaft fracture

 

Must pay attention first to meticulous NOF ORIF

 

Options

1.  Pin and Plate NOF / Retrograde Nail

2.  Pin and Plate NOF / Plate femur

3.  Reconstruction Nail

- difficult to anatomically reduce NOF

- increased incidence NOF non union

4.  Antegrade IMN in place before diagnosis of NOF fracture

- if undisplaced, can place screws anterior to nail

- if displaced must remove nail

 

Dislocated Hip + Femoral shaft fracture

 

1.  Simple dislocation

- may be able to reduce hip with proximal steinman pin

- then IMN femur / retrograde or antegrade

- or plate femur

 

2.  Dislocation with Pipkin

- may need anterior approach to ORIF femoral head fracture

- may be best to plate / retrograde nail femur

 

3.  Dislocation with posterior acetabular fracture

- may need posterior approach to acetabulum

- consider plating femur / distal femoral or tibial steinman pin

- delayed ORIF posterior wall

 

Distal femoral condylar fracture + shaft fracture

 

Options

1.  Screws anterior and posterior to retrograde nail

2.  Distal Locking plate

 

Bilateral Femur Fractures

 

High risk of complications

- blood loss

- nerve injury

- ARDS (double risk unilateral)

- mortality risk (5x unilateral)

- non union

 

Management

- IMN one femur

- assess patient stability

- IMN nail other femur or external fixation / delayed nail

 

Complications

 

Nerve Palsy

 

Pudenal nerve palsy most ommon

- up to 15%

- usually transient

- related to longer traction times

- may be related to the use of smaller posts

 

Malrotation

 

Incidence

 

Common

- need attention to patella and foot position prior to distal locking

 

Diagnosis

 

A.  Clinically

- point both patellas to the ceiling

- foot internally or externally rotated compared to uninjured leg

 

B.  CT

 

Femoral Nail Malrotation CT 1Femoral Nail Malrotation CT 2

 

Management

- remove distal locking screws

- correct rotation

- insert new distal locking screws

 

Distal femoral breach

 

Distal femoral breachDistal Breach ORIF

 

Non union

 

Incidence

- uncommon

- increased with unreammed nails

 

Definition

- not united after 6 months

- no progression for 3 months

 

Options

1.  Dynamisation

2.  Exchange nailing +/- bone graft

3.  Remove nail / plate + bone graft

4.  Augmentation with plating and bone grafting

5.  External Fixation

 

1.  Dynamisation

 

Indication

- stable fractures

- non comminuted / non segmental

 

Wu J Trauma 1997

- 24 nails dynamised 4 - 12 months

- union in 50%

 

2.  Exchange nailing

 

Femoral Non unionExchange Nail Bone Graft

 

Technique

- remove old nail

- ream up to larger size

- insert new larger nail

 

Weresh et al J Orthop Trauma 2000

- 19 patients at least 6 months post

- union in only 50%

 

3.  Removal Nail / Plating / Bone Graft

 

Bellabarab J Orthop Trauma 2001

- 100% union rate

- augment with bone graft

 

4.  Augment with Plate + Bone Graft

 

Ueng J Trauma 1997

- 17 patients, 100% union

 

Infected Non union

 

Management

- removal of nail

- irrigation +++

- antibiotic nail / cover IMN with antibiotic cement

- 6 weeks IV antibiotics

- definitive nail / External fixator

 

Infected Femoral Nail 1Infected Femoral Nail2Infected Femoral Nail3Infected Femoral Nail4

 

Infected Femoral Nail United APInfected Femoral Nail United Lateral

 

Refracture

 

No evidence increased risk if nail removed > 1 year

Femoral Stress Fractures

Femoral Shaft Stress Fracture

 

Site

 

Usually mid or lower femur

 

Types

 

Tension

 

Lateral femur

- can progress to fracture

- high rate of non-union

- should ORIF

 

Stress Fracture Lateral

 

Femoral stress fractureFemoral Stress Fracture IMN

 

Compression 

 

Medial femur

- rare

- usually unite

- NWB

 

Stress Fracture Medial

 

Femoral Neck Stress Fractures

 

Aetiology

 

Athletes with increase activity / distance

Women with eating disorders /  amenorrhea

 

Types

 

Compression / inferior neck

- < 50% protective weight bear

- > 50% emergent ORIF

 

Tension side / superior neck

- emergent ORIF

 

Hip stress fractureFemoral Neck Stress Fracture

 

Hip Stress Fracture Axial CTHip Stress Fracture Coronal CT

 

Hip Stress FractureHIp Stress FractureHip Stress Fracture 3

 

 

 

Hoffa fracture

Definition

 

Coronal plane fracture of distal femoral condyle

- intra-articular

- often only attachment is posterior capsule

 

Epidemiology

 

Rare

 

Mechanism

 

Usually a severe valgus trauma

 

Xray

 

Usually lateral femoral condyle

 

Hoffa Fracture Xray

 

CT / MRI

 

CT

- aids surgical planning

 

MRI

- excludes associated LCL / MCL injury

 

Hoffa Fracture MCL Avulsion MRI 1Hoffa Fracture MCL Avulsion MRI 2

 

Management

 

Issue

 

Usually unstable

- needs ORIF

- can be associated with LCL injuries

 

Must preserve the posterior soft tissue for vascularity

 

Options

 

1.  Buttress screws + AP screws

 

Hoffa Fracture ORIF APHoffa Fracture Lateral

 

2.  Headless compression 6.5mm PA screws

 

Hoffa Fracture ORIF PA screws

 

 

 

 

 

 

 

Infected Femoral Fracture

Management

 

ABx coated IM nail + External Fixator

 

Infected Femoral Nail 1Infected Femoral Nail 2Infected Femoral Nail 3Infected Femoral Nail 4

 

 

 

 

 

Surgical Techniques

Surgical TechniquesAntegrade Femoral Nail

 

1.  Trochanteric Entry Antegrade Femoral Nail

 

Position

- GA, IV ABx

- traction table

- patient legs adducted, torso adducted

- allows access to GT

- flex and abduct other hip for II access

 

Entry

- incision proximal to GT

- split abductors in line

- palpate tip of GT

- check entry point on AP II view

- check entry point on lateral II view (junction anterior 1/3 posterior 2/3)

- entry with awl or 3.2 mm guide wire

- ensure wire doesn't penetrate medial cortex

- use proximal reamer for thickened proximal portion of nail

 

Pass guide wire

- ball tipped

- femoral fractures difficult to reduce with traction

- use reduction tool to reduce in AP and lateral views to pass guidewire

- if having difficulty +++, can perform miniopen incision to pass guide wire

- measure guide wire to determine nail length

 

Note typical deformity of proximal fragment which needs to be corrected

- flexed by psoas

- abducted by G medius

- externally rotated

 

Femoral Shaft Fracture Standard Displacement Lateral

 

Ream

- tight fit best

- nails come in 8.5, 10, 11 and 12 mm

- need to ream 1 - 2 mm larger than nail

 

Pass nail

- attach to proximal locking jig

- ensure drill passes through jig into proximal nail holes

- insert nail

- visualise with II at fracture site

- ensure nail doesn't get caught on one cortex

- excessive hammering in this position can cause fracture

 

Locking

 

Proximal

- usually proximal locking first

- screw should purchase cortex of lesser trochanter

 

Femoral Nail Proximal Locking0001Femoral Nail Proximal Locking0002

 

Distal

- straighten out other leg / lower so can obtain lateral II

- perfect circle technique

- distal locking performed

 

Femoral Nail Distal Locking0001Femoral Nail Distal Locking0002

 

2.  Retrograde Nail

 

Retrograde Femoral NailRetrograde Femoral Nail Lateral

 

Indications

- distal 1/3

- floating knee

- obesity

 

Set up

- patient supine

- put knee over radiolucent triangle / bundle of gowns

- allows entry to knee

- can remove to allow proximal locking

- ensure II for AP proximally locking

 

Entry point

- medial parapatella approach

- entry above ACL origin

- slightly medial

- ensure central in AP and lateral

- awl / 3.2 mm guide wire

- ream for enlarged end of retrograde nail

 

Pass guide wire

- measure length

 

Ream & insert nail

- distal locking performed

- proximal AP locking under II control

 

 

 

Foot And Ankle

Achilles Tendon

Achilles Tendon Rupture

AnatomyAchilles tendon anatomy

 

Gastrocnemius tendon 10-25 cm long

- soleus 3-10 cm

- inserts superior calcaneal tuberosity

- fibres spiral 90°

- fibres that lie medially in proximal portion become posterior distally

- allows elastic recoil & energy storage

 

Plantaris present in 90% population

- medial to T Achilles

 

Poor blood supply midportion

- mesotenal vessels

- fewest at 2-6 cm

- other blood supply from osseous insertion

 

Epidemiology

 

Usually age > 40 years

- M:F = 12:1

- occasional sportsman

- 75% during sports

 

Aetiology

 

Calf contraction with forced dorsiflexion in setting of tendon degeneration

 

Combination of

 

1.  Repetitive microtrauma

2.  Hypovascularity

- occurs at watershed of vascular supply 

- an area of hypovascularity 5 cm proximal to tendon insertion

 

Factors

- corticosteroids - oral or injected

- anabolic steroids

- flouroquinolone / ciprofloxacin (especially elderly)

- gout

- hyperthyroidism

- tendinitis (10% ruptures have preexisting achilles tendon disorder)

- cavovarus OR planovalgus foot

 

Mechanical Overload

- footwear (low heel, inadequate shock absorption)

- sudden training increase

- cross training

 

Classification of Tendon Inflammation

 

1. Paratenonitis 

- inflammation of paratenon

- swelling, pain, crepitation, tenderness, warmth

 

2. Paratenonitis with tendinosis

 

3. Tendinosis 

- intratendinous degeneration due to atrophy

- aging, microtrauma, vascular compromise

- swelling absent

- +/- palpable nodule

 

Rupture Site

 

1.  Watershed area

- 5 cm proximal to insertion

- most common

 

2.  Insertion

- common with insertional tendonitis

 

3.  Musculotendinous juntion

- avulsion of medial or lateral head

- may present with chronic weakness

 

Medial Head Gastrocnemius RuptureMusculotendinous Gastrocnemius Rupture 2

 

NHx (if neglected)

 

Weakness / wasting

- difficulty with push off

- compromised running / jumping / stairs 

- can still walk with use of FHL / FDL / T posterior / Peroneals

 

Calf Wasting Left Leg

 

History

 

Sudden pain in calf

- with audible snap

- on unaccustomed exercise

- especially tennis / squash

 

Examination

 

MAJOR SIGNS (AAOS Clinical Practice Guidelines 2010)

Positive Thompson Test (90% sensitivity and specificity)

- patient prone

- squeezing calf doesn't produce plantarflexion of ankle

 

Thompson Sign Normal PreThompson Sign Normal Post 

Palpable gap (70% Sensitivity and Specificity)

 

Achilles Tendon Rupture 1Achilles Tendon Rupture 1

 

MINOR SIGNS (more difficult to elicit acutely) 

Weak PF

- unable to perform single heel raise 

 

Increased DF comparted to contralateral side

 

Chronic tear

- gap fills with scar tissue

- gap not palpable

- excessive DF compared with other side

 

TA rupture increased DF

 

Xray

Only indicated if associated bony tenderness 

 

Ultrasound

 

Cheap, dynamic, fast

- operator dependant

- check reduction of tendon ends with plantarflexion

 

Acute Achilles Tendon Rupture UltrasoundAcute Achilles Tendon Rupture Reduced with Plantarflexion

 

MRI

 

Indication

- incomplete rupture 

- signs of degeneration

- clinical uncertainty (two major signs not present) 

- measurement of gap in chronic cases / preoperative planning for reconstruction

 

MRI TA rupture chronic

 

Operative v Non-operative Management

 

Issues

 

1.  Complications 

- infection & skin necrosis with operative

- ? re-rupture with non operative

 

2.  Function

- strength & patient return to activity / sports

- ? better function with non operative

 

Meta-analysis 

 

Khan et al JBJS Am 2005

- 12 trials involving 800 patients

- operative treatment associated with lower RR (.27; CI .11 - .64) of rerupture

- higher risk of complications (RR 10.6; CI 4.82 – 23.2) 

 

 

Willits et al JBJS Am 2010 

- 144 patients randomised trial operative v non operative

- concept of accelerated functional rehabilitation in both groups

- 2 weeks NWB

- weight bear in aircast with 2 cm heel raise up to 8 weeks

- able to actively DF / PF below neutral

- no significant difference in rerupture rate or loss of motion / power at all time indices

- 13 complications in operative versus

 

Non-operative

 

Indications

- elderly, DM, PVD, smokers

- non athlete

 

Technique

 

Equinus front slab 

- need to do within 24 hours

- try to close gap before haematoma forms

- change to full cast at 1 week

- debatable if need long leg cast v short leg

- 2 weeks

 

Functional Rehabilition

- heel raise 2 cm and air cast

- FWB for further 6 weeks

- active ROM below neutral

 

Achilles Tendon Boot and heel raise

 

Results

 

Rerupture

- rate unknown

- likely in order of 5%

- likely some minimal loss of plantarflexion strength

 

No risk of infection / wound breakdown

 

Operative

 

Achilles tendon ruptureAchilles tendon repairKrackow suture

 

Indication

- young, active

- athlete 

 

Technique

 

Timing

- ? delay for one week to allow swelling to reduce

 

Position

- prone

- prep both feet to check tension

 

Posteromedial approach

- avoids sural nerve and short saphenous vein

- don’t place scar directly posteriorly / less scar discomfort

- full thickness skin to paratenon

 

Open paratenon and dissect off tendon

- want to repair at end of case on dorsum of tendon

- this reduces skin adhesions

- incise paratenon in the midline anteriorly / increases tissue available for closure

 

Tendon repair

- Bunnell Suture  / Krackow suture x 2 with high strength suture / fibre wire

- one in proximal and one in distal tendon ends

- tie via two knots with foot fully plantar flexed

- augment with circumferential 4.0 prolene to minimise bunching

 

Augmentation

- not usually needed acutely

 

Paratenon repair

- closure posteriorly to aid glide

- prevents adherence to scar

- use 3.0 vicryl

 

Careful skin closure

- LA with adrenalin

- front slab short leg

 

Post operative

- accelerated rehab as above

- jog at 3/12

- sports at 6/12

 

Complications

 

Wound breakdown

 

Debride, manage infection

- vac dressing

- free muscle flap (usually gracilis) + SSG

- fasciocutanous flap (radial or lateral thigh) has better wear characteristics

 

Rerupture

 

Case 1

 

Previously non operative management / new onset severe pain with bump

- intrasubstance / incomplete tear

 

Tendoachilles Nonoperative ReruptureAchilles Tendon Rerupture0001Achilles Tendon Rerupture0002

  

Case 2

 

Acute pain 8 weeks post non operative management rupture

- ultrasound demonstrates scar tissue

- no reduction with plantarflexion

 

Achilles Tendon Scar TissueAchilles Tendon Scar Tissue No Reduction Plantarflexion

 

Reconstruction / Augmentation

 

Indication

 

Unable to primary repair / chronic setting

 

Algorithm

 

< 3cm 

- turndown

 

Achilles Tendon Turndown

 

3 - 5 cm 

- VY lengthening

 

Achilles Tendon VY Turndown

 

VY Advancement

 

> 5 cm 

- FHL / FDL / peroneal transfer

- free gracilis graft

- allograft

 

Chronic TA rupture reconstruction with graft

 

Large gaps

- turndown + FHL

- FHL is most accessible / directly medial to T achilles

 

Techniques

 

VY advancement

 

Turndown / Bosworth technique

 

Harvest central third fascia

- from musculotendinus junction as far proximal as possible

- leave attached distally, detach proximally

- closure fascia above

- tubularise fascia with 2.0 ethibond

- drill hole through calcaneal tuberosity

- pass through calcaneum

- suture to itself

 

Can reinforce with plantaris / FHL / FDL / PB

 

Turndown and FHL Harvest

 

FDL / FHL transfer

 

Medial foot incision

- harvest tendon

- suture distal FDL stump to FHL

 

Medial calf incision

- pull tendon through

- through drill hole in calcaneum

- pass tendon through and suture to itself

 

FHL Transfer 2FHL Transfer 3

 

Peroneus brevis transfer

 

Lateral incision

- divide tendon

 

Standard Posteromedial calf incision

- pass through calcaneal drill hole

 

Augment with plantaris if needed

 

Free Gracilis tendon transfer

Achilles Tendonitis

Definition

 

Inflammation of achilles tendon; insertional or noninsertional

 

Spectrum

 

Tendonitis / Tendonosis / Rupture

 

Anatomy

 

Triceps surae

- medial and lateral gastrocnemius

- soleus

- surrounded by paratenon which allows gliding and supplies nutrition

 

Inserts middle 1/3 calcaneal tuberosity

- 2 x 2 cm area

- 90o rotation distally

 

Retrocalcaneal bursa (x2)

- proper is between tendon and calcaneum

- superficial is between tendon and skin

 

Aetiology

 

1.  Non-insertional form 

 

Younger / fitter / more active patients

- overuse and over training

 

Occurs in area of hypo-vascularity & fibre rotation

- 3-5 cm from insertion

- due to repetitive loading associated with jumping

- Angiofibrotic Dysplasia

 

Risk Factors

 

A.  Pronated foot 

- mid-foot pronation is coupled with IR force on tibia 

- opposite to the normal ER in knee extension

- forces are concentrated at the hypovascular area of TA producing high tensile stresses

 

B.  Heel cord tightness

 

C.  Changes in activity level 

 

2.  Insertional form 

 

Occurs at site of insertion

- more common in the overweight / middle aged / comorbidities

- have combination of tendonitis / retrocalcaneal bursitis / spur

- also occurs in athletes 30s - 40s

 

Risk factors

 

A. Poor women's shoe-wear

 

B. Bony protuberance of Os Calcis 

- Haglund's Deformity / Pump bump

- Patrick Haglund, 1928, Swedish orthopaedic surgeon

- prominence of posterosuperior & lateral calcaneus

- causes impingement & mechanical abrasion of T achilles at insertion

 

Pump Bump Clinical Photo

 

C. Retrocalcaneal Bursitis

- retrocalcaneal bursa lies between tendon & posterior surface of calcaneum

- normal lubricating structure

- may become inflamed

 

Ankle Retrocalcaneal Bursa

 

DDx insertional

- seronegative enteropathy

- gout

- corticosteroids

- oral fluoroquinolones

- hyperlipidaemia

- DISH

 

Pathology

 

Peritendinitis

- inflammation limited to paratenon

 

Tendinosis

- tendon thickened

- focal areas of degeneration

- increased type 3 collagen

- may be partial tear

 

Clinical Features

 

Non Insertional

 

Presentation

- pain 2-6 cm proximal to insertion

- usually worse in morning & post exercise

- may present with tendon rupture

 

Findings

- localised tenderness

- tendon may be palpably thickened

- pain with DF and PF

- DF may be limited

 

Insertional

 

Presentation

- pain at bone-tendon interface

- worse after exercise

 

Findings

- localised tenderness & thickening

- bony lump

- DF may be limited

 

Note:

Some younger patients may present only with pump bump / Haglund's

- no tendonitis

- just problems with foot wear

 

X-ray

 

Haglund's Deformity

- may be calcification of bone-tendon interface with spur in insertional tendonitis

- can define with Pavlow lines / Fowler's angle

 

Achilles Insertional Tendonitis XrayTendoachilles insertional calcification

 

Pavlov 

- lateral weight bearing x-ray

- draw parallel pitch lines

- defines Haglund's deformity to be removed (above second line)

 

Achilles Haglund's and Pavlov linesPavlov's Lines

 

Fowler's angle  

 

Normal < 70°

Abnormal > 80°

 

Fowler's Angle

 

MRI

 

Thickening of the tendon with some intra-substance degeneration

 

Tendoachilles Noninsertional Tendonitis Sagittal MRITendoachilles Noninsertional Tendonitis Axial MRI

 

Non-Insertional Management

 

Non-operative (ELMPOPI) 

 

1) Education 

 

2) Lifestyle modification - Rest 

 

3) Physiotherapy - Alfredson protocol 

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658946/#ref35

- Eccentric exercise program originally devised by Curwi

- Duration extended and scientifically validated by Alfredson 

- 90% success rate if adhered to 

 

4) Orthotics - Heel cups ; raises ; medial arch supports 

 

5) Pharmacologics - NSAIDs

 

6) Injectables - Steroids contraindicated ; alternatives PRP , Autologous blood , sclerosing agents 

Limited evidence for any injectable currently

Gross et al FAI 2013 

http://www.ncbi.nlm.nih.gov/pubmed/23637232

 

Operative

 

Indication

- failure non operative > 12 months

 

Technique

 

Para-tenon resected

- tendon debrided

- tears in tendon repaired

 

Percutaneous vertical tenotomies

- may stimulate revascularisation

 

> 50% tendon degenerative

- may need augmentation

- FDL / FHL

 

Results

 

Rompe Am J Sports Med 2009

- RCT of eccentric v eccentric + ECSW

- improved results with combined treatment

 

Kearney 2012 Foot Ankle Int

- systematic review

- some evidence for eccentric loading and ECSW

- minimal evidence for surgery / case series only

 

Insertional

 

Non-operative

 

As for non-insertional

 

Operative

 

Indication

- if fails to settle in one year

- high risk

- these patients have poor tendon and skin

 

Open / Arthroscopic Technique

 

Supine positioning

 

Sandbags & rolled towel under knee on operative side

 

Tilt bed away from operative side (increases ER)

 

Lateral approach

- preserve sural nerve (blunt dissection superficially)

- open plane between lateral achilles tendon & deep fascia

- usually need release portion of achilles tendon

 

Retrocalcaneal bursa excised

 

Osteotome resection Haglund's if present

 

Resection of bone spur if present

 

Tendon debrided 

- remove inflammed paratenon

- vertical tenotomies

- reattach tendon with anchors

- if tendon severely compromised, transfer required

 

Ankle Arthrodesis

Results 

 

90% fusion rates

 

Lose70% sagittal plane ROM

 

Disadvantages of Arthrodesis 

 

Non union rates up to 12%

Decreased gait speed

Poor mobility over uneven surfaces

Need for shoe modification

Arthritic degeneration in STJ of up to 100%

 

Types

 

Tibiotalar arthrodesis

 

1.  Intra-articular

 

A. Open

- gold standard

- especially significant deformity / mal-alignment

- screws from tibia into talus

 

B. Arthroscopic

- 8 Vs 14 weeks for fusion time

- minimal deformity only

 

2.  Extra-articular / Frame

- children

- sepsis

- osteopenia

 

Tibiotalocalcaneal (TTC)  Intramedullary Nail

- commonly needed in RA

 

Blair Fusion

- refer to talar fracture complications

 

Position

 

1.  5° Valgus

- excess varus causes cavovarus

 

2.  Neutral Dorsiflexion

- if fused in plantar flexion develop genu recurvatum to put foot on floor

 

3.  5-10° ER

 

4.  Tibia anterior on talus

- preserves heel

- decreases lever arm = less energy required for toe-off

 

5.  Subtalar Joint 5°Valgus

- for TTC hindfoot fusion nails 

 

Surgical Techniques 

 

1. Intraarticular Technique 

Dual incision reciprocal flat-cut technique

 

Ankle Fusion APAnkle Fusion Lateral

 

Incision

- over distal fibular, curved forward over ST joint

- inter nervous plane between sural and superficial peroneal nerves

- full thickness down to bone

 

Superficial dissection

- subperiosteally expose distal fibula

- protect peroneal tendons posteriorly

 

Fibula osteotomy / excise distal fibula

- oblique cut ending 1.5 cm proximal to joint

 

Fibula Osteotomy Ankle FusionFibula Osteotomy and Reflected Posteriorly

 

Deep dissection

- expose talar neck anteriorly

- expose tibia posteriorly

- protect anterior tendons and NV bundles with retractors

- protect posterior peroneal tendons with retractors

- open the tibio-talar joint with lamina spreaders

 

Distal tibial cut

- oscillating saw

- perpendicular to tibial axis

- just above subchondral bone / 2-3 mm

- care not to take off medial malleolus

- if cut is too thick, will enter medial malleolus

 

Make a separate antero-medial incision

- medial to T anterior, protect saphenous nerve and vein

- use osteotome to complete tibial cut and protect medial malleolus

- denude medial malleolus of articular cartilage

- also clear medial talus

- note that the deltoid ligament carries the primary blood supply to the talus, and should be preserved

 

Talar dome cut

- place foot in desired position

- 5o valgus and neutral DF

- make a parallel cut to distal tibia

- again only 2-3 mm

- ensure two cuts appose

 

Stimulate bleeding bony surfaces

- drill holes in distal tibia and talar dome / sharp osteotome

- especially if sclerotic bone

 

Position foot

- ER 5 – 10o depending on other foot position

- with respect to patella

- hold with wires for 6.5 mm cannulated screws

 

Fixation

 

Option 1

- medial tibia down to talus

- one into dome & one into neck / parallel

 

Option 2

- lateral talus up to medial tibia

- region sinus tarsus / lateral process

- parallel

 

Supplement

- medial malleolar screw

- fibular to talus screw

 

Check II 

 

Options for fibular 

- discard 

- reattach to tibia and talus as onlay graft 

- morcellize with reamer and insert 

 

Postop 

NWB 6/52 in cast

PWB in moon boot further 6/52

Double time if diabetic

 

2.  External Fixation

 

2 circular rings distal tibia

- 4 half pins

 

2 wires metatarsals

- connect to half ring

 

2 x wires calcaneum

- foot plate

- connect to half ring

 

Rods between and compress

 

3.  Tibiotalocalcaneal (TTC) Fusion 

 

Pantalar Fusion APPantalar Fusion Lateral

 

Technique

- prepare ankle arthrodesis site as per compression arthrodesis

- approach and prepare subtalar joint between peroneus brevis and tertius

- elevate EDB

- stabilize both joints with K wires placed to not interfere with nail insertion 

 

Insertion site

- line from 2nd toe through centre of heel pad

- line in coronal plane / junction anterior & middle 1/3 of heel pad

- should pass through anterior part of posterior facet of calcaneum

- posterior to lateral plantar artery and nerve

- screw fixation in calcaneum and talus (lateral to medial ; possible posterior to anterior calcaneal screw)  

- compression (distally locking and tapping on inserter or company specific jig) 

- 2 x proximal screws medial to lateral 

 

Complications

 

Intraoperative 

-NV Damage 

-Metalwork Breakage 

 

Postoperative 

- Immediate - Infection ; compartment syndrome 

- Medium Term - Delayed or nonunion ; painful malunion 

- Long Term - Stiffness and Gait Changes ; Arthrosis in adjacent joints 

 

Nonunion

 

Arthrodesis nonunionArthrodesis nonunion lateral

Ankle Arthroplasty

Ankle OA Pre ArthroplastyAnkle Arthroplasty APAnkle Arthroplasty Lateral

 

History

 

First generation (late 70s early 80s) 

 

Results

- 80-85% Good / excellent in  short term

- severe osteolysis, aseptic loosening 90% 

 

Problems

- cemented 

- highly constrained

- considerable bone resection

- subsequent revision technically challenging

 

Second Generation (mid 80s onwards) 

 

Design

- semiconstrained

- uncemented

- mobile and fixed bearing options

- bone preserving 

  

Indications

 

1.  Older patient with low demand

 

2.  Other joints arthritic

- degenerative SJT / midtarsal joint

- contra-lateral AKJ AO 

- previous triple arthrodesis

 

Absolute Contraindication

 

Infection (Acute or Chronic) 

Neuroarthropathies i.e Charcot 

PVD

Poor soft tissue envelope

Severe malalignment or instability that cant be corrected intraoperatively 

Major AVN affecting >1/3 of talus 

 

Relative Contra-indication

 

Dx - Posttraumatic worse outcomes than RA which has worse outcomes OA  

 

Age - Younger (worse outcomes in < 50 years) 

 

Ankle OA Post ORIF Ankle OA Arthroplasty APAnkle Arthroplasty post ORIF lateral

 

Minor Malalignment (>10 degrees of varus or valgus as compromises ligament stability) 

 

Instability

 

Stiffness (preoperative ROM = Postoperative ROM) 

 

Minor AVN talus

 

Second Generation Implants

 

STAR

 

Design

- cobalt chrome tibia and talus

- titanium porous coating

- talus single keel

- tibial component two rounded keels

- mobile bearing poly

 

Anderson et al JBJS Am 2004

- 51 STAR

- 12 revisions

- 5 year survival 70%

 

Depuy Agility

 

Design

- fusion of the distal tibio-fibular syndesmosis to support tibial component

- titanium tibial component with cobalt chrome talar resurfacing

- uncemented

- modular poly inserts into tibial component

 

Knecht et al JBJS Am 2004

- 69 followed clinically with 90% reporting decreased pain and satisfactory outcome

- 11% revision rate

- 76% demonstrated peri-implant radiolucency

- 20% progressive subtalar OA and 15% progressive TNJ OA

 

Techique

 

Anterior approach

- protect SPN

- between T ant and NV bundle

- remove anterior osteophytes

 

Tibial cut

- distal alignment jig

- resect few mm above eroded bone

- neutral cut

- must not cut medial or lateral malleolus

 

Talar dome

- resurfaced

- 3-4 mm removed

 

Results

 

Haddad et al JBJS Am 2011

- systemic review

- similar satisfaction rates and and ankle scores in arthroplasty and arthrodesis groups

- 5 and 10 year survival of arthroplasty 77%

- 7% revision rate in arthroplasty (loosening and subsidence)

- 9% revision rate in arthrodesis (non union)

 

Is ankle replacement cost effective compared with arthrodesis?

 

Complications

 

Loosening

 

TAR LooseLoose TAR AP

 

Revision

 

Revision TAR APRevision TAR Lateral

 

Ankle Arthroscopy

IndicationAnkle Arthroscopy

 

Diagnostic

 

Pain / Stiffness / Locking

Instability

- exclude OCD

Assess syndesmosis

 

Therapeutic

 

Synovitis

Osseous lesions / Tibiotalar impingement spurs

Osteochondral defects

Anterolateral impingement lesions (soft tissue)

Loose bodies

 

Ankle Scope Loose BodyAnkle Scope Loose Body 2

 

 

Technique

 

Set up

 

Position

- supine on table

- tourniquet

 

Traction

A.  Assistant provide traction

B.  Foot traction halter

C.  Skeletal distracter

 

Ankle Arthroscopy Traction

 

Instrumentations

- standard knee scope or

- 2.7mm 30° scope

- small scope better for getting across joint line without chondral damage

 

Portals

 

Ankle distended first

- 20 ml syringe, normal saline

- anteromedial

- insert needle, move ankle

- if on bone and needle moves, on talus and need to redirect proximally

- if on bone and needle doesn't move, on tibia and need to redirect inferiorly

- insufflate with 15 mls to create anterior space

 

Portals

- usually want instrumentation on side of pathology

- exception is anterior spurs

- usually large osteophyte laterally so first portal insert medially

 

Ankle Scope Medial and Lateral PortalsAnkle Superficial Peroneal Nerve

 

Anterolateral

- lateral to peroneus tertius

- can then transilluminate and avoid saphenous nerve on AM portal

- structure at risk is branches SPN

- Just proximal to joint line

- incision in skin only

- blunt dissect down to capsule

- insert blunt trochar

- aim anterior to joint to create space

 

Anteromedial

- second portal

- medial to tibialis anterior

- structure at risk is G saphenous vein and saphenous nerve

- use transillumination to avoid

- insert and visualise needle

- skin incision, blunt dissection

- insert shaver, again anteriorly

- clear soft tisse until can visualise joint line

- beware anterior tendons and nerves

 

Technique

 

1.  Inspect anterior talus

- plantarflex foot

- look for chondral lesions

 

2.  Inspect distal tibia

- look for osteophytes

 

3.  Inspect gutters

 

A.  Medial

 

Ankle Arthroscopy Medial GutterAnkle Scope Medial GutterAnkle Scope Medial Gutter

 

B.  Lateral

- exclude meniscoid lesions

 

Ankle scope lateral gutterAnkle Scope Lateral Gutter

 

4.  Look across joint

- distract

- insert probe or shaver and use as level

- look at tibial plafond and syndesmosis

 

Ankle Arthroscopy Lateral GutterAnkle Scope Talar Dome

 

5.  Inspect syndesmosis

- probe and assess stability

 

Ankle scope syndesmosisAnkle scope syndesmosis 2

 

6.  Inspect posterior joint line

 

Ankle Scope Posteromedial CapsuleAnkle scope posterior capsule laterally

 

Posterior Ankle Arthroscopy

 

Posterior ankle arthroscopy

 

Posterolateral

- just lateral to tendo achilles

- medial to fibular

- 1.2-1.5cm above tip of fibula

- sural nerve & vein anterior

- remember joint 1cm higher at back

 

Subtalar Arthroscopy

 

Subtalar arthroscopy

 

Complications

 

Nerve Injury

 

Specific

 

Anterolateral portal - SPN

Anteromedial portal - Saphenous

Posterolateral portal - Sural

Anterocentral - Deep Peroneal

Posteromedial - Posterior Tibial

 

Minimise by

1.  Marking of skin prior to arthroscopy

2.  Transillumination to visualise nerves

3.  Feel nerve 

4.  Use of blunt dissection

 

Mechanism injury

- penetration

- neural structures close to capsule

- anterior penetration by chondrotome may injure DPN

- traction device

- pins in talus and calcaneus may injure sural nerve

 

Other

 

Compartment syndrome

- From extravasation of fluid into calf

 

Articular cartilage damage

 

Infection

 

Pseudoaneurysm

 

Pseudoaneurysm AngiographyPseudoaneurysm MRI

 

Ankle Injuries

Ankle Fracture

AnatomyDislocated Ankle

 

Bony

- 90% load through plafond to talus

- 10% load through lateral talofibular articulation

 

Ligaments

 

A.  Lateral Ligament Complex

 

ATFL (Anterior Talo-Fibular Ligament) 

- tight in plantar flexion

 

CFL (Calcaneo-fibular ligament)

- slopes down & back

- tight in dorsiflexion

 

PTFL (Posterior Talofibular Ligament)

- scissors with Posterior Tibiofibular Ligament

 

B.  Medial Ligaments

 

Superficial Deltoid (SDL)

- origin medial tibia

- broad insertion talus / calcaneum / navicular

- resists hindfoot eversion

 

Deep Deltoid (DDL) 

- tibiotalar

- key to stability / primary stabiliser of ankle

- resists talus ER

- if divided get abnormal ER of talus in plantar flexion

 

C.  Syndesmosis

 

Interosseous Ligament

- between AITFL and PITFL (anterior inferior and posterior inferior tibio-fibular ligament)

 

Biomechanics

  

ROM

- DF = 30°

- PF = 45°

- Rolls & slides to produce DF/PF

 

Plantarflexion

- deltoid ligament acts as a checkrein

- prevents ER of talus

- causes 5° IR talus

 

Dorsiflexion

- talus wider anteriorly 2.5 mm

- fibula moves laterally & ER to accommodate

 

Ramsey 1976

- 1mm talus shift = Contact area decreased by 40%

- non-physiological study

- jammed wedges in intact ankle

 

Ankle Fracture Classification 

 

No system prognostic

 

1.  Weber ABC

 

A.  Fracture distal to syndesmosis

- stable / avulsion type fracture

- FWB

 

Weber A

 

B.  Fracture at level of syndesmosis

- syndesmosis intact

- ORIF if medial structures not intact

- xray below demonstrates Weber B with rupture deltoid ligament

- ankle unstable

 

Ankle Weber B Fracture

 

C.  Fracture above level syndesmosis

- syndesmosis at risk / must assume is torn

- medial structures often torn

 

Ankle Weber C Fracture

 

2.  Lauge-Hansen 1950

 

Two part 

 

1.  Position of talus

- supination tenses lateral structures

- pronation tenses medial structures

 

2.  Direction of force

- rotation or translational injury

 

A. Supination-Adduction

Stage 1: Transverse fracture of lateral malleolus at or below the level of anterior talo-fibular ligament (Weber B) 

Stage 2: Vertical fracture of medial malleolus (often a marginal impaction at medial edge of plafond)

 

Ankle Fracture Supination Adduction

 

B.  Supination-External Rotation (Most common - up to 85% all injuries)

Stage 1: Rupture of AITFL

Stage 2: Short oblique fracture of the lateral malleolus (Weber B) (stable)

Stage 3: Rupture of PITFL / fracture of posterior malleolus of tibia

Stage 4: Transverse fracture of medial malleolus (unstable) 

 

Ankle Fracture Supination ER

 

C. Pronation-Abduction (Less than 5% of ankle fractures)

Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus

Stage 2: Rupture of the anterior and posterior inferior tibiotalofibular ligaments or bony avulsion

Stage 3: Proximal fibula fracture (often butterfly)

 

Ankle Pronation Abduction

 

D. Pronation-External Rotation

Stage 1: Rupture of the deltoid ligament or transverse fracture of the medial malleolus

Stage 2: Rupture of the anterior inferior tibiotalofibular ligaments or bony avulsion

Stage 3: Spiral/Oblique fracture of the fibula above the level of the syndesmosis        

Stage 4: Rupture of the posterior inferior tibiofibular ligament or fracture of the posterior malleolus

 

Ankle Fracture Pronation External Rotation

 

X-ray assessment

 

3 standard views

 

AP, lateral and mortise

 

Ankle AP XrayAnkle Mortise View

 

Mortise

 

Technique

- foot internally rotated

- AP projection

- should be symmetrical clear space around talus

 

Ankle Mortise View

 

1.  Lateral talar shift / increased medial clear space

- medial clear space > superior clear space

- should be < 4mm

- indicates injury to medial structures

- instability

 

Ankle Fracture Increased Medial Clear SpaceAnkle Fracture Increased Medial Clear Space 2

 

2.  Tibia / fibular overlap < 1mm / syndesmotic injury

 

Ankle Fracture Syndesmosis WidenedAnkle Diastasis

 

Incidence

 

Unimalleolar 70%

Bimalleolar 25%

Trimalleolar 7%

Open 2%

 

Management

 

Principles

 

Reduction

- protects skin medially

- conscious sedation in emergency department

- well moulded POP

- unstable ankles need monitoring for loss of reduction

- can need external fixation to maintain position

 

Ankle Fracture Severely Dislocated Dislocated Ankle Lateral

 

Timing

- operate when swelling reduced

- usually < 6 hours or 6 days

- higher risk with bimalleolar / 2 incision operations

- risk not being able to close wounds / infection

 

Long term results rely on

- reduction of talus under tibia

- mechanical stability

- degree of chondral damage

 

Medial ligament injury is the key to management

 

1.  Isolated Lateral Malleolar / Weber B Fracture

 

Ankle Fracture Isolated Weber BIsolated Fibula Fracture 3 mm displaced

 

Definition

- no medial fracture / no complete deep deltoid injury

- no increased medial clear space

- no instability on stress ER views

- no syndesmotic injury

 

Pathology

 

85% have no medial injury

- by definition have no talar shift 

 

LM displacement not important if medial side not injured

- Biomechanical studies show Talus doesn't follow LM when axially loaded if medial ligament  intact 

- Doesn't lead to altered biomechanics

 

There is no external rotation of the distal fragment 

- its relationship to the talus is fixed

- the proximal fragment is internally rotated

- again, this does not alter the biomechanics

 

Diagnostic Dilemma / Is the deltoid ligament intact?

 

Examination

 

A.  Non tender / no bruising

- is intact

- non operative management

 

B.  Tender / bruising

- may be partially injury sprained / or completely ruptured and unstable

- inconclusive

 

Lateral BruisingMedial bruising

 

Xray

 

1.  Mortise view

- any increased clear space

- ORIF

 

2.  Stress views

 

Option A:  Gravity Stress View

- Patient lies injured side down, cross table xray

- see if medial clear space opens

 

Option B:  Valgus view

- lead gloves

- can be painful as patient has acute injury

 

Option C:  EUA

 

Results of Isolated Weber B Fibular Fracture

 

Results of surgical and non surgical management equally good

- Talus is stable if medial ligament is intact

- If  < 3mm fibula displacement, nil poor outcome

 

Non operative

- Kristensen and Hansen etal

- 95% good outcome non operatively

- no salvage operations required for post-traumatic arthritis

 

Operative

- 1-3% chance of serious infection

- more long term swelling

 

Management

 

Cast in Internal Rotation to reduce the deformity

 

2.  Bi Malleolar Injury

 

Types

 

A.  Medial Malleolus and Lateral Malleolus Fractured

 

Ankle Fracture Bimalleolar

 

B.  Deltoid tear + Lateral Malleolus Fractured

 

Ankle Fracture Weber B + Deltoid Ligament

 

If have talar shift, then by definition bi-malleolar injury

- must be an interruption to medial structures

 

Results

 

Superior results with operative management

- able to obtain and maintain anatomical reduction

- 90% good results

 

Closed treatment

- for elderly or medically unfit

- acceptable reduction / ankle internally rotated

- 60% good results

 

Surgery

 

1.  Weber B + Medial Malleolus fracture

 

Fibula

- interfragmentary lag screw

- derotation 1/3 tubular plate

 

Medial malleolus (dependant on fragment size)

- 2 partially threaded lag screws

- 1 screw and one k wire

- TBW

 

Screen syndesmosis

- should be stable with Weber B

- stress view (ER and dorsiflexion)

- cotton test (clamp on fibula and attempt to open syndesmosis under II)

 

Ankle Fracture Bimalleolar ORIFAnkle Fracture Bimalleolar ORIF

 

2.  Weber B + Deltoid Ligament

 

Ankle Weber B Deltoid Ligament InjuryAnkle Weber B Deltoid Ligament ORIF

 

A.  Manage Fibula as above

- ensure joint fully reduced

 

Ankle Fracture Fibula ORIF Increased Medial Clear Space

 

B.  Medial clear space remains open

- ensure fibular out to length and anatomical

- assess syndesmosis intact / reduce and fix

- if remains open, must be suspicious of OCD fragment or deltoid ligament blocking medial reduction

- may need to open medially

 

No evidence that repair of medial ligament improves results

 

3.  Tri-Malleolar Fracture

 

Posterior malleolus

 

Anatomy

- avulsion of PITFL

 

Ankle Fracture Small Posterior Malleolus Xray

 

Ankle instability results if

- > 1/3 articular surface (>30%)

- displacement of > 2mm 

- risk posterior subluxation of the tibio-talar joint

 

Issue

- these can be highly unstable and require external fixation

 

Trimalleolar UnstableTrimalleolar Unstable

 

Ankle External Fixator APAnkle External Fixator Lateral

 

Indications to ORIF posterior malleolus

- usually get anatomical reduction after plating of LM

- ORIF if > 30% and > 2mm displaced

 

 Ankle Fracture Large Posterior Malleolus XrayAnkle Fracture Large Posterior Malleolus CT

 

Surgical Options

 

1.  Posterolateral approach to fibula

- enable AP clamp to reduce and hold fracture

- anterolateral approach

- front to back screws

 

2.  Formal posterolateral approach

- patient lateral or prone

- PA screws or buttress plate

 

Posterior Malleolus LargePosterior tibial buttress plate

 

Ankle Fracture Trimalleolar ORIFAnkle Fracture Trimalleolar ORIF Lateral

 

4.  Syndesmosis Injury

 

Ankle Fracture Clear Syndesmotic Injury

 

Definition

 

Disruption of syndesmosis between level of fracture and plafond

- distal tibia and fibular not connected and stable

 

Situations

 

A.  Weber C fracture

- extremely high risk

- almost always safer to ORIF

 

Ankle Weber C Syndesmotic InjuryAnkle Weber C Syndesmotic Screw

 

B.  Weber B fracture + medial column injury

- occasionally syndesmotic injury

- check intraoperatively

 

C.  Maisonnerve injury

- high fibula fracture

- medial clear space opening / deltoid injury

- need diastasis screw

 

Ankle Fracture Maisonnerve InjuryAnkle Fracture Maisonnerve Proximal Fibula

 

D.  Isolated Injury

 

Ankle DiastasisORIF Diastasis

 

Intraoperative tests

 

Cotton test

Stress test

 

Management

 

Reduction technique

- foot in neutral, clamp across medial and lateral malleolus

- don't reduce in plantarflexion as posterior talus is more narrow

- don't over reduce the joint

- check symmetrical joint space on mortise view

 

Diastasis Screw Fixation technique

 

1.  With other LM / MM fracture

- 1 or 2 screws

- 3 or 4 cortices

- 3.5 or 4.5 mm

- at level of epiphyseal scar

 

Ankle Fracture Diastasis Screw

 

2.  High Weber C fibula / Maisonnerve

- don't have to plate fibula

- ensure fibula out to length

- usually 2 screws
 

Post op

 

Need screw in for 8 - 10 weeks

- need to await ligament healing

- NWB

- usually remove screw as will break

 

Ankle Broken Diastasis Screws

 

5.  Medial Malleolar Fractures

 

Medial Malleolus Fracture

 

Management

 

Displaced

- ORIF

- 20% risk of non union

 

Undisplaced

- can usually manage in cast

- still small risk of non union

 

Fixation

 

A.  Large fragment

- 2 x screws

 

Ankle Fracture Medial Malleolus 2 Screws

 

B.  Small fragment

- screw + K wire

- TBW

 

Ankle Fracture Medial Malleolus TBW

 

C.  Plate

- vertical fractures

 

Medial Malleolus Plate

 

6.  Open Ankle Fractures

 

Presentations

 

Compound Ankle Fracture

 

Clean & Closeable wound

- wound usually medial

- washout / ORIF / close

 

Dirty wound / wounds need skin cover

- external fixation

- wound management

- ORIF later

 

7.  DM

 

Risks

- amputation (6% open, 40% closed)

- infection

- malunion / non union / delayed union

 

Increased in patient with neuropathy and PVD

 

Management

- increase fixation

- double NWB times

- leave sutures in for twice as long

 

8.  Elderly / Osteoporotic

 

Issue

- bone very poor

- good fixation difficult

 

Ankle Fracture OsteoporoticAnkle Osteoporotic Fixation

 

Complication

 

Non-union 

- uncommon

- Improve for up to 9 yrs

 

Medial Malleolus Non union

 

Swelling 

- worse after ORIF 

- continues > 3/12

 

Fibula malunion 

- decreases tibiotalar contact by 30%

- correction <4 years = Good results

 

Infection 1-4%

 

Missed fractures

- plafond fractures

- chondral lesions (50%)

- anterior process calcaneum

 

RSD

 

Stiffness

 

OA

 

Ankle OA Post ORIF

 

Complex Ankle Sprain

Definition

 

Simple sprain 

- injury to ATFL

- will almost always get better in 6-8/52

 

Complex sprain 

- associated injury

- suspect if patient slow to recover 

- diagnose most things on MRI

 

Symptoms

 

Instability

- clinical diagnosis 

- most will get better with appropriate physio

 

Pain

- if pain is present as well then consider other pathology

- isolated instability isn't usually painful

 

Causes

 

1.  Soft tissue

- lateral gutter fibrosis

- Bassett's ligament (thicknened AITFL)

- meniscoid / ferkel lesion

 

2.  Bony Injury

- OCD / loose body

- bone bruise

- fracture anterior calcaneum / lateral process / sustenaculum tali

 

3.  Tendon / ligament

- deltoid

- peroneal dislocation / tears

- high ankle sprain / syndesmotic injury

- sinus tarsi syndrome

- Achilles tendonitis

 

DDx

 

Soft Tissue

 

1.  Lateral gutter fibrosis

 

Ligament healing thicker than normal 

- associated scar tissue

- initial injury seemed to get better 

- ongoing pain and swelling over lateral ankle

 

Management

- arthroscopy and debride

- most will get better

 

2. Bassett's Lesion

 

Pathology

 

Primary injury to AITFL

- tear may produce laxity

- talar dome may extrude anteriorly in DF

 

AITFL

- normally thin and above level of ankle joint

- may become thickened and scarred causing lateral ankle pain and swelling

 

Diagnosis

 

Difficult to diagnose

- tender in syndesmosis & interosseous membrane

- positive squeeze test

 

Management

- arthroscopy and debride

- most will get better

 

3.  Meniscoid Lesion

 

Definition

 

Scar tissue beginning in the lateral gutter

- extending across between tibia and talus

- looks like a meniscus

 

Management

- arthroscopy and debride

- most get better

 

Bony Injury

 

1.  Fracture Anterior process of calcaneum

 

Pathology

 

Avulsion of the origin of the bifurcate ligament

- often missed if x-ray is in the wrong plane

 

Calcaneum Anterior Process Fracture

 

Diagnosis

 

Suspect if tender over anterior calcaneus

- CT or more plain films

 

Calcaneum Anterior Process Non Union

 

Management

- non-op for 6/12 

- most will unite or get a painless fibrous nonunion

 

2.  Fracture Lateral Process

 

Pathology

 

Eversion injury leading to lateral ankle pain

- tends to be larger than appears on plain x-ray

- often cause stiffness as involves STJ

 

Diagnosis

 

CT / MRI

 

Management

 

ORIF 

- > 1cm

- displaced > 2mm

 

Small and comminuted 

- excise

 

3.  Fracture Sustenaculum Tali

 

Caused by impaction on medial malleolus as the talus internally rotates

 

Management

- usually treat non-operatively

 

4.  Fractured Os peroneum 

 

Pain distally over the CCJ

 

Management

- non-operative initially

- late excise 

 

5.  Bone bruise

 

Pathology

 

Oedema in bone usually medial talar body and medial malleolus

- initial injury settles 

- get pain with resumption of activity

 

Diagnosis

 

MRI 

 

Management

 

Usually settles in 6/12

 

5.  Osteochondral fracture

 

Mechanism

- occur as the talus is inverted within the mortise

 

Pathology

 

Anterolateral 

- caused by shear stresses as the lateral talus abuts the lateral malleolus 

- tend to be smaller and generally do better

 

Posteromedial 

- caused with medial ridge impacting the roof

- more significant injury

- tends to be larger with underlying necrotic bone

 

6.  Loose Body

 

Tendon / Ligament

 

1.  Deltoid Tear

 

Pathology

- severe injury / almost an ankle dislocation

- gross inversion of talus with distraction 

- complete tear of lateral structures and tear of deltoid

- medial pain with lateral sprain

 

Management

 

Initially treat non-operatively

- may need debridement / repair

 

2.  High Ankle Sprain

 

Pathology

 

Injury to AITFL

- point tenderness and swelling

 

Management

 

Exclude diastasis

 

Treat non-operatively

- will take 12 weeks

 

Can benefit from late debridement

 

3.  Peroneal Dislocation

 

Pathology

 

Occurs with inversion while plantar flexed (strong contraction of peroneals)

- more common in cavus type feet 

- usually not diagnosed at the time

 

Symptoms

 

Patient complaining of painful snapping or clicking on lateral ankle

- after ~ 1/12 get synovial lined pouch anterior to malleolus from chronic subluxation

- won't heal

 

Management

 

Operative

- surgery with repair &/or deepening of groove

- repair and augment with periosteal flap or slip of Tendo achilles

 

4.  Peroneal Tear

 

Single or multiple longitudinal split

- associate with subluxation / dislocation

- associated with cavus feet

 

5.  Sinus Tarsi Syndrome

 

Lateral ankle pain

- injury to interosseous ligament

- residual synovitis

 

Management

- HCLA

- excision of contents of sinus

 

6.  Achilles tendonitis

 

Insertional tendonitis

Retrocalcaneal bursitis

Haglund' s deformity

 

 

 

 

Deltoid Ligament

 

Epidemiology

 

Incidence isolated deltoid ligament injury 2.5%

 

Anatomy

 

Strong fan-shaped structure 

- composed of a deep and superficial layer

 

Superficial layer 

- inserts as one continuous structure 

- navicular anteriorly, spring ligament (calcaneonavicular), sustentaculum, and calcaneum 

- measures 10 mm wide at its origin and 2 to 3 mm thick

- length varies from 20 to 30 mm

 

Deep layer

- inserts onto the nonarticular medial wall of the talus 

- most of the fibers concentrated on the posterior medial aspect of the talus

 

Management

 

Isolated deltoid injuries are extremely rare 

- need proximal fibular xrays to exclude maisonneuve injury & / or syndesmotic injury

- treated in a cast or brace

 

 

 

Lateral Ligament Complex

Acute Injury

Definition

 

Partial or complete rupture of one or parts of lateral ligaments of ankle

- common ankle sprain

 

Epidemiology

 

Lateral ligaments sprains are the most common ligamentous injuries of the human body

- account for approximately 15% of all athletic injuries

- it is estimated that there is one ankle inversion injury per day per 10,000 people

 

Most common young males

- average age 27

- M:F 2.5 : 1

- common injury in sport 

- basketball & soccer

- 10% emergency consults

 

NHx

 

Up to 20% to 40% of ankle sprains treated conservatively have some residual symptoms

- undertreatment is more common than overtreatment

- inadequate treatment can result in chronic ankle instability with recurrent sprains and early degenerative arthritis

- 10% of lateral ligament injuries will have subtalar instability also

 

Aetiology

 

Inversion injury

- jumping sports

- land plantarflexed and inverted

 

Associations

 

Peroneal muscle weakness

Pes Cavus

Tarsal Coalition

 

Anatomy

 

The ankle is a uniaxial joint that resembles a mortise and tenon

 

It is very stable when loaded in the neutral position

- bony contact and stability decrease with plantar flexion

 

1.  ATFL 

 

The most frequently injured ligament in the human body

 

Dimension

- 15 to 20 mm long, 6 to 10 mm wide, and 2 mm thick on average

 

Anatomy

- arises anterior aspect fibula, 1 cm above tip, 2 cm long, attaches 8 mm above STJ

 

Action

- primary restraint to anterior displacement, internal rotation, and inversion of the talus at all flexion angles

- in cadaveric studies, the ATFL always failed first

 

2.  CFL 

 

Cylindrical structure

- lies deep to the peroneal tendons

- 2.5 times stronger than the ATFL

 

Dimension

- 20 to 30 mm long, 3 to 5 mm thick, and 4 to 8 mm wide

 

Anatomy

- arises tip fibular, 2 cm long

- subtends angle 130 degrees from fibula

- attaches 13 mm below STJ

 

Action

- crosses two joints and acts as a subtalar joint stabilizer

- isolated CFL ruptures rare

- the ATFL and the CFL function together at all positions of ankle flexion to provide lateral ankle stability  

 

3.  PTFL 

 

The strongest of the lateral ligaments

- least often injured

 

Dimensions

- 30 mm long, 5 mm wide, and 5 to 8 mm thick

 

Anatomy

- medial surface of lateral malleolus to posterior lip talus

 

Ankle MRI PTFLMRI Ankle Intact PTFL

 

Pathology

 

Most are mid-substance tears

- avulsion injuries occur in about 14%

 

Findings

- isolated ATFL tear is most common injury(60% to 70%)

- combined ATFL / CFL tear (20%)

- isolated CFL, PTFL, & subtalar ligament ruptures all very rare

 

Examination

 

Tenderness

 

Fingertip palpation of all structures 

- shown to be almost as accurate and more cost-effective than the tests available

 

Instability testing

 

Controversial & unreliable without anaesthesia in acute setting  (LA or GA)

 

1.  Anterior drawer 

 

Most important & best predictor ATFL

- 10° plantarflexion neutral rotation

- CFL plays no role

 

> 3mm is positive

 

Ankle Anterior Drawer

 

2.  Talar tilt 

 

CFL test / subtalar instability

- 10% of patients with lateral ligament instability also have subtalar instability

 

Patient seated / foot unsupported

- 10-20° PF

- stabilise tibia /  gentle inversion

- compare to other side

 

> 20o abnormal

 

Talar Tilt

 

Investigations

 

X-rays

 

Advisable with significant ankle injuries / unable to weight bear

- AP, Mortise & Lateral views

- +/- AP Foot

 

Look for OCD / Weber A fibula

 

High resolution CT & MRI

 

Exclude OCD if needed

Not required acutely

Define injury in chronic situation

 

Grading Acute Injury

 

Grade I 

 

Mild injury with minimal swelling and tenderness and slight or no functional loss

- ankle is stable 

- negative drawer and talar tilt tests

 

Considered to be a partial tear

- patient can perform normal activities but with pain

 

Grade II 

 

Moderate injury with diffuse swelling and tenderness

- moderate functional loss with difficulty with toe walking

- partial stability is lost 

- mildly positive anterior drawer  (ATFL complete tear) 

- negative talar tilt (CFL partial tear only)

 

Partial to possibly complete tear of the ATFL and a possible partial tear of the CFL

- patient cannot perform normal activities and can bear weight but with increased pain

 

Grade III 

 

Severe injury

- significant functional loss and marked tenderness, swelling, and pain

- lateral ankle stability is lost 

- positive drawer and talar tilt tests

 

Considered to signify a double ligament injury with complete rupture of the ATFL and CFL

- weight bearing is usually not tolerated

 

Acute Management

 

Grade I & II Injuries 

 

Mechanically stable 

 

Benefit from protection 

- stirrup-type brace or high boot

- until nonprotected weight bearing is relatively pain-free

 

Ankle Orthosis

 

During the protected period 

- non-weightbearing ROM exercises are performed

 

Progressing to proprioceptive & ultimately agility training

- shown to shorten the period of disability

- Grade I ankle sprain should be near full recovery at 1-2 weeks

- Grade II ankle sprain at 2-3 weeks (may take a lot longer)

 

Grade III Injuries

 

Mechanically unstable by definition

 

Previously thought to all require surgery but now shown to be successfully treated non-operatively

 

1.  Casting for 4-6 weeks 

- in slight dorsiflexion & eversion to approximate ligament ends

- then functional rehabilitation

 

2.  Functional Bracing

- removable brace

- progressive weightbearing

- ROM, proprioception & strengthening exercises

- success demonstrated with MRI studies

 

Moonboot

 

Rehabilitation

 

Kannus Meta-analysis

 

Functional treatment superior in

- time to return to work

- physical activity

- ROM

- less wasting

- complications

 

No difference in

- instability 

- pain, swelling & stiffness

- re-injury

 

Protocols

 

Strapping

- figure 8 weave

- in neutral DF & slight ER

- shortens ATFL & helps proprioception

 

Physiotherapy

- peronei rehab is the key

- proprioception exercises

 

Return to Sport 

- successful performance of simple tests provide adequate guidelines

- ability to run, cut and jump 10 times on the single injured foot

- to stand on one foot with eyes closed for one minute 

- all without excessive pain

- athletes can return to sports when they are able to run and pivot without pain while the ankle is braced

- bracing or taping for sports is continued for 6 months after injury

 

Outcome

 

Most return to work by 8/52

20% have pain that limits activity

20 - 40% will have recurrent sprains

 

 

Chronic Ankle Instability

Definition

 

Chronic instability due to rupture of one or more parts of the lateral ligament

 

Anatomy

 

Progressive injury

1. Anterolateral capsule

2. ATFL

3. CFL

 

NHx

 

Can lead to ankle OA over time

 

Ankle OA Post Lateral Ligament Instability

 

History

 

Swelling over anterolateral ankle

 

Giving way with inversion

- occurs with activity & walking on uneven ground

- stiffness, locking, crepitation

 

Chronic pain is unusual with isolated chronic instability

 

Examination

 

Tender & swelling over involved ligaments

- anterior to lateral malleolus for ATFL 

- inferior to lateral malleolus for CFL

 

Limited dorsiflexion

 

Calf atrophy (especially peroneal)

 

Instability

- depends on ligaments involved

 

ATFL Instability

 

1.   Positive Anterior Drawer

- anterior subluxation on anterior drawer of talus on tibia

- ankle in 10° PF

 

Ankle Anterior Draw

 

2.  Increased inversion on varus stress with AJ in PF 

 

CFL Instability

 

1.  Increased inversion on varus stress with AJ in DF

 

2.  Positive Talar Tilt

 

Talar TIlt

 

ATFL & CFL instability

 

1.  Increased inversion on varus stress in all positions of AJ

 

2.  Positive Anterior Drawer and Talar Tilt

 

Stress Xrays

 

Plain xray usually normal

- look for OCD

- medial aspect of talus

 

1.  Talar Tilt 

 

Best to supervise personally, use lead gloves

- mortise view

- AJ 10o PF

- > 10° side to side difference

 

2.  Anterior Drawer

 

AJ 10° PF knee flexed

- side to side diff 3mm

- > 10mm on single film

 

MRI

 

Will demonstrate tears of ATFL / CFL

 

MRI Torn ATFL Axial VewAnkle MRI CFL

 

DDx

 

Bone

- tibiofibular synostosis

- stress fractures (calcaneum)

- intra-articular fracture / OCD

- lateral talar process

 

Ligament 

- syndesmosis strain

 

Tendon

- peroneal tendonitis / subluxation / dislocation

 

Nerve / RSD

 

Sinus tarsi syndrome

- pain & tenderness over lateral opening sinus tarsi

- inversion injury

- tear of interosseous talocalcaneal ligament

- usually heals but can get synovitis

 

Mechanical Instability vs Functional Instability

 

Mechanical 

- beyond physiologic range

- >10mm anterior drawer / >10° talar tilt

 

Functional 

- ankle giving way during ADL's

 

Classification O'Donoghue

 

Grade 1

 

Partial Tear ATFL or CFL

- incomplete injury

- negative Anterior Draw clinically and on xray

- negative Talar Tilt clinically and on xray

 

Grade 2

 

Torn ATFL +/- partial CFL

- positive Anterior Draw clinically and on xray

- negative Talar Tilt clinically and on xray

 

Grade 3

 

Torn ATFL & CFL

- positive Anterior Draw clinically and on xray

- positive Talar Tilt clinically and on xray

 

Management

 

Non-operative  (90%)

 

Rehabilitation programme

- strengthen of peronei

- proprioception (wobble board)

 

Shoe-wear modification with lateral flared heel

 

Operative Management

 

Indication

 

Instability with failure of non-operative treatment

Patient not willing to accept the discomfort 

 

Options

 

1.  Anatomic repair / modified brostrom

2.  Advancement

3.  Augmentation of repairs

 

1.  Anatomic Repair / Modified Brostrom

 

Procedure

- mid substance repair

- often attenuated 

 

Advantages

- restore normal anatomy & mechanics

- no donor site morbidity or weakening

 

Gould Modification

 

Technique

- suturing extensor retinaculum over ATFL repair

 

Advantages of modification

- reinforces repair

- limits inversion

- correct STJ part of instability (present in 10%)

 

Inferior extensor retinaculum anatomy

- laterally arises from anterior surface calcaneum

- medially has 2 limbs - med malleolus & plantar aponeurosis

 

Results

 

85% G/E without Gould modification

95% G/E with Gould modification

 

Poor outcome

1.  Generalised ligamentous laxity

2.  >10 yrs instability

3.  Previous operations

4.  Ankle osteoarthrosis

 

2.  Fibular advancement of ATFL / CFL

 

Technique

 

EUA
- confirm talar tilt / anterior draw

 

Longitudinal incision anterior to lateral malleolus

- protect branches of SPN

- expose tissue of ATFL / CFL

- can often feel them

- tissue is broad and diffuse

 

Lateral Ligament Repair IncisionLateral Ligament Repair Flap Incisions

 

Dissect out two flaps

- anterior incision between ATFL and CFL to talus

- begins at tip of fibula to talus

- superior flap is ATFL

- take off fibula as broad / thick flap

- inferior flap is CFL

- need to protect peroneals with inferior portion of dissection

 

First Transverse IncisionATFL FlapInferior CFL Flap

 

Inspect talar dome for OCD

- place retractor across talar dome

- ensure no loose bodies

- can remove anterior ankle osteophyte if necessary

 

Place foot in eversion and AJ neutral

 

Inferior AnchorAnterior Anchor

 

2 x 3.5 mm anchors in fibula

- ensure not in joint and not prominent

- 4 sutures through ATFL

- 2 through CFL

- 2 sutures either side of interval of ATFL and CFL so can close this

 

4 Sutures ATFL2 Sutures Inferior Flap2 Sutures to Close Interval

 

Make sure FROM & anterior drawer is negative at end

 

Extensor retinaculum is sutured over the site

- over ATFL

- over anterior aspect of fibula

 

Post op

- weight bear in moon boot for 6/52

- sport 3/12

 

Ankle Ligament Reconstruction APAnkle Lateral Ligament Reconstruction Lateral

 

3.  Augmented Repairs

 

Technique

- most use peroneus brevis (PB)

 

Indications

- poor tissue for anatomic repair

- long standing instability

- hypermobile STJ / ligamentous laxity

- previous surgery / revision

 

A. Chrisman & Snook

 

Reconstructs ATFL + CFL

- stabilizes the STJ

- preserves 1/2 PB

- most widely used non-anatomic reconstruction

 

Good results in 90%

- restricted inversion (100%) and dorsiflexion (20%)

 

Technique

- split PB in 2 leaving 1/2 attached to 5th MT base

- drill fibula transversely in AP direction

- drill calcaneus with small tunnel inferior to fibula

- thread tendon from fibula anterior to posterior & then into calcaneus 

- then back onto PB / PL or to PB anterior to fibula

 

B.  Evans

 

Tenodesis of PB

- divide proximally

- re-route through drill hole from anteroinferior tip to postero-superior

- pass PB through & suture to proximal end

- will also limit SJ motion

 

Baltopoulis et al. CORR 2004

- 27 patients, average AOFAS score 91

- 1/3 restricted hindfoot movement

 

C. Watson-Jones

 

Attempt to recreate ATFL with PB tenodesis

- detach PB tendon as proximally as possible

- drill hole through fibula transversely 1 inch from tip

- drill second hole through talar neck

- thread tendon through fibular posterior to anterior

- then through talus superior to inferior

- suture back to itself over LM

- limits STJ motion

 

D. Colville

 

Anatomic reconstruction CFL and ATFL

- 1/2 PB left attached distally

- through calcaneal tunnel

- to tip fibula tunnel to anterior fibula 8mm proximally

- to talar neck tunnel and back to anterior tibia

- idea is not to restrict STJ movement

Os Trigonum FHL Impingement

Posterior Ankle Impingement

 

Epidemiology

 

Repetitive plantar flexion

- soccer players, ballet dancers

 

Cause

 

Os trigonum

FHL stenosing tenosynovitis

Soft tissue mass

 

Os Trigonum

 

Secondary centre of ossification of talus

- lateral to groove for FHL

- 2-7% of normal feet

- impinges against plafond with forced PF

- can cause FHL tenosynovitis

 

Os TrigonumOs TrigonumOs Trigonum

 

Examination

 

Pain with forced plantarflexion

Pain with resisted FHL

 

MRI

 

Classically

- synovitis over posterolateral process talus

- fluid in sheath about FHL

 

May also see

- posterior tibia bone oedema

- thickened posterior capsule

- os trigonum

 

Management

 

Non Operative

 

US guided HCLA

- good results reported

 

Operative

 

Options

 

1.  Lateral approach

 

Indication

- resection of os trigonum only

 

2.  Medial approach

 

Indication

- also release of FHL

 

Technique

- incision between medial malleolus and T achilles

- T post, FDL and neurovascular bundle anterior

- release FHL compartment, look for accessory muscle or nodule

- open capsule over os trigonum

- excise

- need to ensure don't damage posterior talus articular cartilage

 

Os Trigonum Skin MarkingOs Trigonum Skin IncisionOs Trigonum Superfical Dissection

 

Os Trigonum FHLOs Trigonum FHL Accessory MuscleOs Trigonum Capsule

 

Os Trigonum ExposedOs Trigonum ExcisedOs Trigonum Posterior Talus Cartilage

 

FHL Tenosynovitis

 

Clinical

 

Pain behind medial malleolus

Pain with stressing FHL

 

Xray

 

No os trigonum

 

Arthroscopic release

 

FHL Arthroscopic Release 1FHL Arthroscopic Release 2

 

Subtalar Dislocation

Epidemiology

 

Rare

 

Types

 

Medial

- 80%

- calcaneum dislocated medially

 

Lateral

- 20%

- higher energy injury

 

Subtalar Dislocation Xray 1Subtalar Dislocation Xray 2

 

Anterior / Posterior

- extremely rare

 

Pathology

 

Tearing of strong interosseous ligament

 

Dislocation of

- talonavicular joint

- talo-calcaneal

 

Reduction

 

Subtalar dislocationSubtalar dislocation 2

 

Conscious sedation

- flex knee to relax gastrocnemius

- increase deformity

- reduce calcaneum whilst holding talus

 

Blocks to reduction

- medially - talar head buttonholes through capsule / EDB

- laterally - tibialis posterior

 

Post reduction

 

CT

- exclude intra-articular fragments

- ensure congruent reduction

 

CT post subtalar dislocationCT post subtalar dislocation 2

 

Results

 

Main risk is restricted ROM

- very difficult to treat surgically

- usually stable after reduction

- don't immobilize for long or subtalar joint will stiffen

 

Risk of osteochondral injury and later OA


 

 

 

 

Syndesmotic Injuries

Definition

 

High ankle sprain

 

Epidemiology

 

Uncommon

- often unrecognised or misdiagnosed as lateral ligament injuries

- seen in ice hockey

 

1-15% of ankle sprains involve the syndesmosis

 

Mechanism Injury

 

Hyperdorsiflexion and forced external rotation

 

Anatomy

 

Structures

- anterior inferior tibiofibular ligament (AITFL)

- posterior inferior tibiofibular ligament (PITFL)

- interosseous ligament (provides only 10% of strength)

 

Ankle MRI AITFL PITFLSyndesmosis MRI Normal

 

Examination

 

High Ankle Sprain Clinical

 

1.  Tenderness over the AITFL

 

2.  Positive squeeze test 

- pain at ankle with squeezing the tibia & fibula at mid-calf

 

3.  Painful ER

- probably most reliable test

- neutral ankle with knee flexed 90o

- hold tibia in neutral

- externally rotate foot

 

Xray

 

Usually is no evidence of syndesmotic widening

 

Ankle AP Xray Syndesmotic MeasurementsAnkle Mortice Xray Syndesmotic Measurements

 

3 reliable indicators of syndesmotic widening

 

1.  Clear space 

- between the medial border of the fibula and the lateral border of the posterior tibia (incisura fibularis)

- measured 1 cm above the plafond

- distance should be approximately 5 mm or less on both the AP and mortise views in the normal ankle 

 

2.  Overlap of the fibula and the anterior tibial tubercle

- greater than 6 mm on the AP views

- greater than 1 mm on the mortise view

 

3.  Stress films for syndesmotic instability

- application of an external rotation and abduction force

- anesthesia is often required because of the painful nature of this examination

 

Syndesmosis stress view

 

Chronic

 

May see HO / MO interosseous ligament

 

Ankle Interosseous HO

 

CT

 

Normal

 

CT Syndesmosis normal

 

MRI

 

Highly accurate

- see disruption of ligament

- bone contusions posteromedial talus and posteromedial tibia

 

High Ankle Sprain MRI 1High Ankle Sprain MRI 2

 

Syndesmosis Injury T1Syndesmosis injury T2

 

Arthroscopy

 

Inspect the syndesmosis under external rotation stress test

- see widening > 2mm between tibia and fibula

- can also visualise AITFL and PITFL

- often a tibial chondral injury

 

Management

 

1.  Xray evidence of widening

 

Syndesmosis InjurySyndesmosis TightropeSyndesmosis Tightrope 2

 

Management

- diastasis screw / tightrope

 

2.  Syndesmotic injury with no widening

 

Takes 6 - 12 weeks to resolve

- impossible to strap

- WBAT but no impact sports 6 weeks

 

3.  Chronic injury / pain

 

Ogilvie-Harris Arthroscopy 1994

- arthroscopic debridement of sydesmosis and chondral injuries in 19 patients

- good results reported

- elimination of external rotation test

 

Ankle MRI

Deltoid Ligament

 

Deep Deltoid Ligament

 

Ankle Coronal MRI

 

Superficial Deltoid Ligament

 

Ankle MRI Superficial Deltoid LigamentSuperficial Deltoid MRI

 

Lateral Ligament Complex

 

PTFL

 

Ankle MRI PTFL

 

PTFL / CFL

 

Lateral Ligaments

 

Syndesmosis

 

MRI AITFL PITFL

 

Peroneal Tendons

 

Ankle Sagittal MRI

 

 

 

 

Ankle OA

AetiologyAnkle OA

 

Trauma

 

A. Ankle Fracture
 

Types

- Weber A 4%
- Weber C 33%
- Displaced large posterior malleolar

 

Any OA develops in first 2 years

 

Causes

- articular damage at time of injury
- non anatomical reconstruction
- complications i.e. infection

 

B. Plafond Fracture

 

C. Talus Injury

 

Talar Dome OCD

Talus AVN

Talar neck malunion

 

Other

 

Inflammatory OA

Infection

Hemochromatosis

Hemophilia

Charcot

 

Incidence

 

Ankle OA much lower than hip or knee

 

Anatomy

 

Thin cartilage 1 mm

 

Joint highly congruent

 

Tibio-talar contact stresses
- 1mm shift causes 40% decrease in contact area
- medial instability more important than lateral instability

 

Clinically

 

Pain

- with weight bearing

- nightime

 

Stiff Ankle Joint

 

Xray

 

Ranges from

- anterior spurring

- severe OA

 

Ankle Xray Anterior Tibial OsteophyteAnkle OA Kissing Spurs

 

Ankle OA AP XrayAnkle OA Lateral Xray

 

CT

 

Useful to define small anterior osteophytes

- may be causing pain with excessive dorsiflexion

 

Ankle CT Anterior Osteophyte

 

MRI

 

Ankle OA MRI

 

Ankle OA Coronal MRIAnkle OA Sagittal MRI

 

Management

 

Non Operative

 

Solid Ankle Foot Cushion (SACH) + rocker bottom sole

Analgesia

HCLA / Hyaluronic acid Injections

 

Operative Options

 

1.  Arthroscopic debridement

 

Technique 1

- debride chondral lesions
- microfracture / abrasion

 

Ankle Scope Medial OA

 

Technique 2

- removing kissing osteophytes

- anterior tibial and talar neck osteophytes

 

Ankle Spurs with Anterior ImpingementAnkle Scope Anterior Tibial OsteophyteAnkle Scope Osteophyte Debridement

 

2. Articular distraction with external fixator

 

Technique

- apply for 4/12
- distracted 5 mm
- reasonable results reported
- up to 3 years improvement
- delays arthrodesis

 

3.  Ankle Arthrodesis

 

4.  Ankle Replacement

 

 

 

 

Calcaneal Fractures

Background

Anatomy

 

3 facets

 

1.  Posterior facet (STJ)

2.  Middle facet (sustenaculum tali)

3.  Anterior facet (on distal medial aspect)

 

Anterior process 

- forms calcaneocuboid (CCJ) articulation

 

Thalamic portion 

- under lateral process talus

 

Tuberosities

 

Posterior tuberosity 

- posterior process / T Achilles attachment

 

Medial tuberosity 

- ABDH, FDB, plantar fascia, ADM, Flex Acc

 

Lateral tuberosity

- ADM, long plantar ligament, Flex Acc

 

Aetiology

 

Usually fall from height

- heel in valgus

 

Lateral process talus strikes Crucial Angle Guisanne 

- primary fracture line

- calcaneus driven up against talus

 

MVA

 

Direct blow

 

Essex-Lopresti Classification

 

A.  Extra-Articular  (25%) 

 

Anterior Process fracture

Avulsion of Posterior Tuberosity

Medial & lateral Tuberosity

Sustentaculum Tali

Extra-articular body fractures

 

B.  Intra-Articular (75%) 

 

Epidemiology

- 10% bilateral

- 10% associated with lumbar spine fracture

 

Primary Fracture Line of Palmer

- lateral process of talus driven into crucial angle

- starts at lateral wall near tarsal sinus at crucial angle (in coronal plane)

- passes obliquely across posterior facet

- position of line within the posterior facet variable

- may be medial towards S Tali, middle or lateral towards wall   

- exits at medial wall posterior to sustentaculum tali

 

Produces 2 main fragments

 

1.  Tuberosity / Lateral wall / Variable amount posterior facet

- usually comminuted

- usually displaces superiorly & laterally

 

2.  Sustentaculum / Anterior / Middle facet

- usually undisplaced

 

Sub-classified

- based on appearance of secondary fracture line on lateral X-ray

 

1.  Tongue type (20%)

- secondary fracture line passes posteriorly along calcaneal body to exit laterally below T Ach          

- tuberosity fragment attached to articular fragment (thalamic fragment)

 

Calcaneal Fracture Tongue TypeCalcaneal Fracture Intra-articular

 

2.  Joint Depression (80%)

- secondary fracture line also exits posteriorly

- passes immediately behind the posterior facet of the subtalar joint              

- exits posterior to posterior facet & anterior to T Ach insertion

- creates thalamic portion containing posterior facet

 

Calcaneal Fracture Joint Depression

 

Fracture Anatomy

 

1. Sustenacular Fragment

- constant

- supero-medial 

- attached to talus by deltoid lig

 

2. Superolateral fragment

- thalamic fragment

- lateral fragment of posterior facet

 

3. Lateral wall fragment

 

4. Tuberosity fragment

- posterior heel

 

Examination

 

EMST

 

Lumbar spine

- log roll

- injury in 10%

 

Other heel

- 10% bilateral

 

Foot

- compartment syndrome

 

Effects

- loss heel height

- increased heel width

- varus heel

 

X-ray Views

 

Lateral

- Bohler's angle

- crucial angle Guisane

 

Calcaneal Fracture Lateral

 

Harris axial views

- 45o axial of heel

- normally hindfoot 10o of valgus

- view varus malalignment & heel width

 

Calcaneal Fracture Harris Axial ViewCalcaneal Fracture Harris Axial View

 

Oblique view

- CCJ

 

Calcaneal Fracture Oblique Xray

 

Broden's view

- visualise posterior facet

- IR foot 45 degrees with ankle neutral initially

- plantar flex the foot 10° increments from 10° to 40

- alternatively angle beam cephalad in 10 degree increments

- replaced by CT

- useful intra-op to assess congruency of STJ

 

Xray Angles

 

1.  Bohler's angle  (20-40°)

 

Highest point on anterior process to highest point on posterior facet to highest point on tuberosity

- represents the height of the calcaneus

- angle of </=0° is associated with a poor outcome

 

Indicates

- the posterior facet/ STJ  has collapsed

- proximal displacement of tuberosity

 

Calcaneum Normal Bohlers AngleCalcaneal Fracture Reduced Bohlers Angle

 

2.  Crucial Angle Guisane 120-140°

- lies inferior to lat process of the talus

- where the primary fracture line starts

- disrupted in joint depression fracture

 

Formed by 2 cortical struts

a) lateral border of posterior facet

b) anterior to beak of calcaneus

 

Thus see

- decrease in Bohlers angle

- increase in Gissanes angle 

 

CT scan

 

3 mm cuts

- foot flat on table

- transverse and coronal

- sagittal reconstruction

 

1. Axial

- parallel to bottom of foot

- information regarding CCJ & sustentaculum

 

Calcaneal Fracture Axial CT

 

2. Coronal plane

- perpendicular to posterior facet

- information regarding posterior facet and number of fragments +

- sustentaculum / heel shape / position peroneal & FHL tendons

 

Calcaneal Fracture Coronal CT

 

3.  Sagittal

- Bohlers angle / depression of posterior facet

 

Calcaneal Fracture Lateral CTCalcaneal Fracture Lateral CT

 

Sanders Coronal CT Classification

 

Summary

- calcaneum divided into 3 columns by 2 lines

- based on lateral, central & middle columns of posterior facet

- number of longitudinal fracture lines on coronal CT through post facet

 

Position

- patient positioned supine in scanner with hips & knees flexed 45°

 

Type I 

- undisplaced, irrespective of number of parts

- cast

 

Type II 

- 2 parts of the posterior facet

- > 2mm displacement

- subgroups A,B,C based on primary fracture line

- more medial the fracture line (C), the more difficult to ORIF

 

Calcaneal Fracture Sanders 2

 

Type III 

- 3 part (AB, AC, BC)

- ORIF / fusion

 

Calcaneal Fracture Sanders 3 CT

 

Type IV 

- highly comminuted

- primary fusion

Complications

Early

 

Wound necrosis

 

Superficial infection 17%

 

Sural nerve neuroma

 

Intra-articular hardware penetration

 

Compartment Syndrome 10%

 

Deep infection

- Debridement and removal of metalwork

- Free flap over Abx beads, IV ABx

- Late grafting and STJ OA

 

Late

 

RSD

 

Non union

 

Heel pad problems

 

OA 

- STJ & CCJ

- may require arthrodesis

 

Malunion

 

Calcaneal Malunion

 

Stephens and Sander's classification

 

Issues

- varus hindfoot locks Midfoot

- shortened foot / shortened lever arm

- peroneal impingement

- shoewear problems

 

Options

 

1.  Lateral wall exostectomy and peroneal tenolysis

 

2.  Above + STJ arthrodesis

 

3.  Above + calcaneal osteotomy

- this may not allow the wound to be closed

- may need to do so gradually with frame

 

 

 

 

Management Extra-articular Fractures

1.  Anterior process

 

Part of complex sprain / easily missed

- non operative if small

- ORIF if large and displaced

 

2.  Tuberosity fractures

 

Need ORIF if displaced

- have T Achilles attached and can put skin under threat

- ORIF (usually closed reduction and screw)

 

Calcaneum Tuberosity Fracture

 

3.  Body fractures

 

Non operative treatment

 

4.  Sustentacular fractures

 

Sustenaculum Fracture CT 1Sustenaculum Fracture CT 2

 

ORIF if displaced

- medial approach with buttress plate

 

 

 

Management Intra-articular Fractures

Operative v Nonoperative Literature

 

1.  Buckley etal JBJS Am 2002

 

Prospective multi-centred RCT

- 309 displaced intra-articular fractures

- operative v non operative management

- 2 year follow up

 

Findings

- used patient orientated functional outcomes

- overall VAS and SF36 not significantly different between 2 groups

 

Improved Operative Outcome if

- not workers compensation

- women

- < 29

- bohler's angle 0 - 14 initially (not -56 to -1)

- light workload (not heavy manual worker)

- anatomical reduction < 2mm (CT of post facet)

- type 2 sanders (types 3 and 4 did not)

 

Note:

Any patient who required a subtalar arthrodesis to relieve pain was removed from the study.  

A non operatively treated patient was 5.5 x more likely to need this operation!

 

Complications  

- 5% deep infection

- 17% superficial infection

- STJ arthrodesis: non operative 17%, operative 3%

 

2.  Sanders 1993

 

Heel shape restored in 98+%

- Type II - 85% reduction and 75% good results

- Type III - 60% reduction and 70% good results

- Type IV - no anatomical reduction and 10% good results

 

Conclusion:

Sanders classification gives guide of prognosis

Once posterior facet is in more than 3 parts, good outcome decreases drastically

 

3.  Stulik etal JBJS Br 2006

 

287 displaced intra-articular fractures

- 1 year follow up

- Sanders 2, 3, 4

 

Any patient excluded from ORIF but amenable to OT

- DM / smokers / vascular insufficiency / compound wound / severe fracture blisters

 

Treatment

- MUA & Gissane spike percutanous reduction

- additional K wires

 

Results

- 16.5% excellent, 55.7% good

- 14.8% fair and 13% poor

- Sanders 2 > 4

 

Complications

- 1.7% deep infection

- 7% superficial infection

- nil amputation

 

Conclusion:  

There are intermediate options between ORIF and non operative

- with the ability to somewhat restore heel height and width

- in high risk patients who cannot have ORIF

- probably makes subsequent fusion easier

 

4.  Poeze et al JBJS Am 2008

 

Calcaneal volume load v outcome

- centres with higher volume load

- reduced rates of deep infection and subsequent subtalar arthrodesis

 

5.  Heller JBJS Am 2003

 

43 compound calcaneal fractures

- wound usually medial

 

Type I ORIF

- no infections in 7/7

 

Type II 

- 3/8 infection

 

Type IIIA

- 3/12 infection

 

Type IIIB

- 10 /13 infection 

- 6 /13 became deep osteomyelitis

- 3 required amputation

 

Conclusion

- very dangerous to ORIF anything other than Type I compound fracture

- a quarter to a third of type II and IIIA will get a deep infection

- absolutely not in any patient who will need a flap

 

6.  Folk et al JOT 1999

 

If patient had DM + PVD + smoker, wound problem rates > 90%

 

5. Rodger Atkins AOA 2000

 

Salvage arthrodesis very difficult

- Always better to attempt reconstruction initially even if just to make arthrodesis easier

- Alternative is Primary Arthrodesis

 

Management

 

Aims

 

Pain free functional foot that can fit in a shoe

 

Goals

 

1.  Restore heel shape (height, length and width)

2.  Reduce joint surface

 

Options

 

1. Non-operative

2. ORIF

3. Primary STJ arthrodesis

4. Salvage / STJ arthrodesis

 

Issues

 

1.  Patient factors

 

Smoking 

- higher incidence infection

- try to get them to stop

 

DM, PVD

- high risk of infection

 

Heavy manual workers 

- will find it difficult to return to work

 

Bilateral fractures

- do worse

 

Gender

- women do better

 

Age

- younger do best

 

2.  Soft tissue envelope

 

Compound fractures

- wound medial

- operative for Type 1

 

3.  Fracture type

 

Bohler's angle

- if less than 0o initially, do poorly however managed

 

Sander's

- prognostic (type I do well, type IV high rates fusion)

- lateral wall fragments easier to fix (2A)

- very medial fractures (2C) very difficult

 

Assess

- Bohler's angle

- Posterior facet / Sanders

- CCJ joint

- lateral wall fragment

- sustentaculum fragment

- tuberosity / heel in valgus

 

4.  Surgeons experience

 

Non Operative Management

 

Indications

- non displaced

- Bohler's > 20

- Sanders IV

- DM, PVD

- compound fracture Type 2 & 3 

 

Technique

- elevate +++

- POP

- NWB 6/52

- Then progressive WB

 

Complications

- STJ OA

- peroneal impingement or subluxation

- calcaneocuboid arthritis

- malunion of hindfoot

- posterior tibial nerve entrapment

- difficulty with show wear

 

Operative

 

Indications

- healthy patient

- ? smoking

- Saunders II / III

- Bohler's < 20o

- displaced tongue type fractures

 

Contra-Indications

- severely comminuted sustentaculum tali

- type IV

 

Needs to be an individualised approach with risk stratification

 

Initial

- Bed rest, elevation, ice & compression till skin wrinkles evident

- between 1 week and 4 weeks

 

Blisters

- clear fluid (some epidermis attached to dermis)

- bloody fluid (no epidermis attached to dermis)

- shown that there is some increased risk of wound problems if incision passes through blisters

 

1.  ORIF  

 

Calcaneal ORIFCalcaneal ORIF LateralCalcaneal ORIF Axial

 

Technique

 

Position

- patient on side, blankets under foot

- operated foot up

- radiolucent table, II available

- GA, IV Abx, tourniquet

 

Incision

- extensile lateral approach

- behind posterior edge of fibula

- anterior to T Achilles

- sural nerve posteriorly in flap

- along borders of calcaneum (Abd H below)

- keep distal cut along inferior margin calcaneum

- angle up towards CCJ

 

Superficial dissection

- elevate full thickness flap with peroneal tendons

- down to bone

- divide CFL

- K wires to retract skin flap

- 2 in talus / 1 in fibula

- expose CCJ

 

Bleeding

- calcaneal artery

- branch of peroneal artery

 

Steinmann pin to tuberosity 

- through heel skin

- can elevate and pull out of varus

 

Hinge lateral wall fragment 

- opens on posterior / inferior periosteum

- gives access to subtalar joint

- if type 2C may need lateral wall osteotomy

- divide interosseous ligament 

- homan or lamina spreader to expose STJ

 

ORIF

- Reduce medial fragments and work laterally

 

1. Restore posterior facet with screws

2. Restore calcaneum height and Bohler's by reducing tuberosity fragment

3. Pull out of varus

4.  Reduce posterior facet & lateral joint fragment onto sustentaculum fragment

- golden screw

- 3.5 mm screw

- aimed anteriorly, medially and slightly upwards

5.  Elevate anterior process fragment

6.  Locking contoured plate

 

Intra-operative II

- lateral

- Broden's view

 

Closure

- careful haemostasis

- closure over drain

- elevate +++ for one week

 

Post op

- NWB 12 weeks

- early ROM exercises once wound healed (2-4 weeks)

 

2.  Essex-Lopresti closed reduction and percutaneous pinning 

 

Indications

- tongue type fractures 

- joint depression fractures not suitable for ORIF

- compound fractures

 

A.  Technique 1 for IA Fractures

 

Position

- patient prone with knee flexed

 

1st steinmann pin (if comminuted IA)

- from medial to lateral through body

- traction to restore height

- correct varus

- manually compress heel to reduce lateral wall displacement

 

2nd steinmann pin

- Posteromedial corner of posterior tuberosity

- aim towards sole and towards CCJ

- under thalamic portion, then lever pin dorsally

- aiming to correct Bohler's

- then aim towards CCJ and can even pass through

 

Incorporate 2 pins into plaster

- remove after 6 weeks

 

B.  Technique 2 Stulik et al JBJS Br 2006 for IA Fractures

 

Calcaneal Fracture Percutaneous Pinning

 

Transverse Steinmann as above

- disimpact fragments

- pull out of varus

 

Plantar stab incision

- posterior facet elevated with bone punch

 

Longitudinal Steinmann pins x 2

- elevate and hold thalamic portion

 

Transverse K wires under posterior facet

 

Results

- 1.7% deep infection

- 7% superficial infection

 

C.  Technique 3 for IA fractures

 

Percutaneous screws + Ilizarov

 

D.  Technique 4 Stulik et al for tongue type

 

Reduce tongue with longitudinal Steinmann

 

Fix with 2 mm K wire / screws

 

Calcaneal Fracture Tongue TypeCalcaneum Fracture Tongue Type ORIF

 

3.  STJ Arthrodesis

 

Indications

- type IV Sanders

- late STJ OA

 

Early

- ORIF with lateral plate

- 2 x 6.5 mm screws

 

Late

- In setting on previous fracture very difficult

- Still have to restore anatomy

- restore heel height & width 

- may have skin problems if have very planovalgus foot

- may need lateral bone block

- need lateral wall ostectomy

 

Calcaneal Fracture OA FusionCalcaneal Fracture OA Post Fusion

 

 

 

 

Charcot

Charcot Joint

Charcot Foot AP Charcot Foot Lateral

 

Definition

 

Neuropathic Arthropathy

 

Progressive destructive arthropathy 2° to neurological condition

- usually minimal to no trauma

 

Aetiology

 

DM

- western world

 

Leprosy / syphilis

- third world

 

Other

- polio

- paraplegia

- syringomyelia

 

Pathophysiology

 

Likely combination of :

 

1.  Neuro-traumatic theory

- cumulative trauma in insensate foot unrecognised

- results in progressive joint destruction

 

2.  Neurovascular theory

- neurally stimulated vascular reflex

- stimulates bone resorption

 

Newer theory: due to inflammatory cytokines

(TNF Alpha & IL-1) = stimulates osteoclast resorption  

 

Classification Temporal - Eichenholtz

 

Sidney N Eichenholtz, American surgeon, 1966

 

Stage 0

 

- added by Shibata et al 1990

- clinical signs (swelling/ erythema) precede XRay changes

- NWB during this period may prevent XRay changes

 

Stage 1 Dissolution

 

Findings

- acute inflammation (swollen, red, warm)

- DDx infection

- erythema reduces with elevation 10 minutes

 

Charcot FootCharcot Foot Elevated

 

X-ray

- demineralisation of regional bone

- periarticular fragmentation

- joint dislocation

- hyperaemia precedes fragmentation by hours to weeks

 

Charcot Foot Stage 1 Fragmentation

  

Treatment

- TCC remains gold standard

- WBAT ; no evidence that better outcomes with NWB

- applied weekly until clinical progression to stage II

- frequency of application may decrease as progress

 

Stage 2 Coalescence

 

Findings

- inflammation decreases / less swelling

- reduced temperature

 

X-ray

- absorption of osseous debris

- organization and early healing of fracture fragments

- periosteal new bone formation

 

Charcot Foot Stage 2 Resolution

 

Treatment

- TCC or transition to CROW (Charcot Resistant Orthotic Walker)i.e bivalved AFO

- may need to modify CROW a number of times before stage III

 

CROW

 

Stage 3 Reconstruction

 

Findings

- normal temperature

- swelling reduced

- clinically stable

 

X-ray

- smoothing of edges

- sclerosis, osseous or fibrous ankylosis

- complete bone healing 

- resolution of osteopenia

 

Charcot Foot Stage 3 Consolidation

 

Treatment

- accommodative shoes with custom moulded orthotic

- CROW or AFO if ongoing ankle instability

 

Px

- 30% will relapse between stages

- 7% risk of BKA without ulcer

- 28% risk of BKA with ulceration

 

Classification Anatomical - Brodsky

 

James Brodsky; Orthopaedic F&A Surgeon; Dallas Tx ; 1993

 

Type 1 Midfoot (60%)

- metatarsocuneiform and naviculocuneiform

- collapse of the medial longitudinal arch with rocker bottom foot

- progress through Eichenholtz stages quicker

- may present stage III with bony prominences & DFU

 

Charcot Midfoot

 

Type 2 - Hindfoot (30%)

- any / all subtalar joint i.e TNJ; subtalar; calcaneocuboid

- more instability than type 1

- require longer periods immobilisation

- varus or valgus

 

Charcot Hindfoot

 

Type 3 (10%) 

3a

- tibiotalar joint

- usually post ankle fracture

- most unstable pattern

 

3b

- pathologic fracture calcaneal tubercle

- weak push-off and ulceration

 

Investigation

 

DDx infection

- MRI

- combination labelled WCC + Bone Scan if MRI CI

 

Management

 

Goal 

 

Stable plantigrade foot that is shoe-able or braceable

 

Few require operative surgery

- control with casts and braces

 

Indications For Surgery 

 

1.  Severe deformity unable to brace

 

2.  Marked instability (usually type II or IIIa)

 

3.  Ulcers

- common type 1

- aim to try and heal ulcer first

- may be caused by fixed bony deformity i.e. midfoot collapse

 

4.  Soft tissues at risk

 

Contra-Indications

 

Uncontrolled diabetes

PVD

Medically unwell

Stage 1 disease

 

Goals of Operative Management

 

Restore alignment & stability so brace &/or shoe can be worn

- prevent alternative which is amputation

 

Timing of Surgery

 

Operating in stage 1 or 2 remains very controversial

 

Correct deformity in resolution / consolidation stage III 

- after cast / brace, shoe failed

 

Acute Fractures

 

Issue

- is it charcot or non charcot?

 

1.  Likely Charcot

 

Patient

- fracture a week or 2 old / red & swollen

- peripheral neuropathy & displaced fracture

- mimimal trauma

 

Eichenholtz I

- treat non-operatively

 

2.  Non Charcot 

 

Truly acute fracture

- reasonable trauma

- patient has peripheral neuropathy / DM

- treat as per usual, but accept higher complication rate

 

Management

- ORIF early before acute (dissolution) phase sets in

- if delayed be wary of ORIF as bone stock very poor

- need very strong and augmented ORIF

- must warn of risk of Charcot in acute fracture

- with peripheral neuropathy double period of immobilisation

- NWB 3/12 then further 3-4 month in TCC

 

Surgical procedures

 

1.  Midfoot ostectomy

 

Charcot Midfoot CollapseNeuropathic Ulcers from midfoot collapse

 

Midfoot most common site for neuropathic destruction

- mid foot collapse 

- apex of rocker-bottom common site for recurrent ulceration

 

Technique Ostectomy

 

1.  Attempt to heal ulcer first

- TCC

- debridement +/- IV ABs if OM

 

2.  Remove bony prominence causing ulcer

- medial or lateral incision

- avoid areas of ulceration

- full thickness soft tissue dissection to expose exostosis

- remove with osteotome / saw

- smooth edges with rasp

- haemostasis

- closure over drain; compressive dressing

- postoperative TCC for 6/52

 

2.  Hindfoot Realignment & Arthrodesis

 

Indications

- hindfoot Charcot not amenable to bracing 

- severe deformity or instability following failed bracing

- amputation is only alternative

 

Amputation v Arthrodesis

 

May develop bilateral issues

- try to avoid bilateral amputations

 

Contraindications to Arthrodesis

1. Disease Factors

 - Active infection (consider staged)

 - Stage I Eichenholtz

 - Insufficient soft tissue coverage

 - Insufficient bone stock

2. Patient Factors

 - Uncontrolled DM or malnutrition

 - Nonreconstructable PVD 

 - Non-compliant  

 

Technique

 

Preoperative

- cast / TCC till Stage III

- optimise HBA1c and nutrition

 

Intraoperative

- longitudinal incisions with full thickness flaps under no tension

- meticulous soft tissue handling

- resect bone to correct deformity

- strongest fixation device possible ; often augmented

- if using hindfoot nail ensure >200mm length

(risk of tibial stress fractures with shorter nail)

- often need percutaneous T Achilles lengthening

- alternative: fine wire fixation if active infection

 

Postoperative

- TCC - 3/12 NWB ; 1/12 PWB; 1/12 WBAT

- Lifelong AFO

- Periodic 6/12 follow-up

 

Results

- Lowery FAI 2012 - 76% bony fusion; 22% fibrous ; 1.2% amputation

- fibrous union can still result in good function

Total Contact Cast

Total Contact Cast 1Total Contact Cast

 

Mechanism

 

TCC’s heal ulcers by reducing pressure

- 1/3 of load is taken by wall of cast & transmitted to the leg

- 45% reduction in forefoot pressure but not heel pressure

 

Works best if closely applied & moulded to leg

 

Goals

 

Protection from trauma

Immobilize

Reduce oedema

Reduce pressure over ulcers

Redistributes pressure over a greater weight bearing surface

 

Indications

 

1.  Superficial forefoot and midfoot plantar ulceration

 

Neuropathic Midfoot Ulcers

 

Deeper ulcers with exposed tendon & bone

- require surgical debridement to convert them to superficial ulcers prior to TCC

 

2.  Eichenholtz stage I or II neuroarthropathic fractures

 

3.  Post operative neuropathic foot surgery

- post-op immobilisation after ORIF of acute fractures

- after reconstruction of deformity

 

Contraindications

 

1.  Heel ulcers

- not effective

- heel ulcers typically have ischaemic component & osteomyelitis

- TCCs don’t reduce heel pressure

 

2.  Deep infection

- abscess, osteomyelitis, gangrene

- beware of ulcer with drainage

 

Treat infection with rest in bed / NWB / Antibiotics

 

If ulcer is deeper than wide

- surgically debride to open ulcer

- allow deeper layers to heal & convert to superficial ulcer

 

3.  Poor skin quality

- especially if on steroids or have stasis ulcers

 

4.  Severe arterial insufficiency (pre-gangrenous feet)

- ABI < 0.45

- Doppler toe pressure < 30mmHg

- TcPO2 < 30

 

5.  Poor patient compliance

- must attend follow up & follow cast precautians

 

TCC Application

 

Technique

 

TCC Toe PaddingTCC Padding Bony Prominences

 

Meticulous

- absorbent gauze on ulcer

- enclose the toes with gauze between toes to reduce moisture

- seamless stocking

- felt over bony prominences

- avoid overpadding the cast / increases shear forces

- well moulded POP / fibre glass

 

Post Application Protocol

 

First 6 weeks

- change weekly

- because oedema subsides quickly

- photos of ulcer at each change

 

Then 2 weekly

- until ulcer healed / Stage 2 Charcot

 

6 months / orthosis

- CROW (Charcot restraint orthotic walker)

 

 

 

Compartment Syndrome Foot

Incidence

 

10% of calcaneus fractures 

40% of crush injuries

 

Diagnosis

 

High index of suspicion / classic signs less reliable

 

Pain & pain with passive stretch remain the cardinal signs

- pallor, paresthesia, pulselessness, & paralysis occur later or sometimes not at all

- low threshold calcaneal compartment pressures & surgical exploration

 

Anatomy

 

Nerve supply sole of foot

 

1.  Medial calcaneal 

- posterior weight bearing surface

 

2.  Medial plantar

- medial 3 & 1/2 sensation

- AbdH, FHB, 1st lumbrical

 

3.  Lateral plantar

- lateral 1 & 1/2 

 

4 muscle layers of the foot

 

Layer 1 (3)

- 3 short muscles that cover the sole

- AbdDM, FDB, AbdH

 

Layer 2 (3)

- long tendons to the digits

- FDL, Flexor accessorius, FHL

 

Layer 3 (3)

- short muscles of the digits

- FHB, AddH, FDMB

 

Layer 4 (3)

- plantar / dorsal interossei and tendons

- P longus, T posterior & interossei

 

4 Compartments

 

Septae from the plantar fascia

- insert 1st and 5th metatarsals

- separate medial / calcaneal and lateral compartments

 

1. Medial 

- ABDH & FHB 

 

2. Central / Calcaneal compartment

- superficial: FDB

- deep: ADDH / F accessorius

 

3. Lateral 

- FDM & AbDDM

 

4. Interosseous 

- interossei

 

The calcaneal compartment communicateswith the deep post compartment of the leg through the medial retro-malleolar space

 

Management

 

3 incision emergent decompression

 

Two dorsal longitudinal incisions

- medial aspect of the 2nd MT

- lateral aspect of the 4th MT 

- release interossei compartments

 

One 6-cm medial incision

- begins at the post margin of MM

- distally along the sole 

- open ABDH & 1st MT interval

- release medial / calcaneal / lateral compartments

- DPC or split-thickness skin grafting at 5 days

 

Non Treated Compartment Syndrome

 

Deformities

- claw toes

- cavus

- FDL tethering

 

DDx / Posterior leg compartment syndrome / FDL involvement

- if the deformity decreases with PF of ankle

- FDL muscle & deep post compartment of leg are involved

 

Diabetic Foot

Background

Diabetic Foot Pathophysiology 

 

1. Neuropathy

2. Arteriopathy

3. Immunopathy

 

Neuropathy 

 

Most important aetiologic factor in foot disease. Due to : 

- metabolic (glycosylation of nerves)

- ischaemic factors 

 

A.  Sensory Neuropathy

 

Definition

- loss of protective sensation - level of sensory loss allows damage to occur without being “painful”

 

Distribution

- stocking i.e. affects longest fibers first

 

Diagnosis

1) Semmes Weinstein 5.07 monofilament

- applies 10gm of force

- defines the presence & severity of neuropathy 

- tip pressed against skin until starts to bend; patient asked if they can feel it

- no standardized number of testing sites

- 90% of patients who are able to feel won’t ulcerate

 

2) 128 Hz Tuning Fork

- Less predictive of ulceration

 

B.  Autonomic Neuropathy

 

20 – 40% of Diabetics

- skin dry / scaly / Cracked  

- easier access for bacteria

 

C.  Motor Neuropathy

 

Loss of intrinsic muscle balance = claw & hammer toes

- Achilles tendon contraction = MT head pressure 

- Results in IPJ dorsal & MT head plantar ulcers

 

Arteriopathy 

 

50% of diabetic foot ulcers (DFU) have arteriopathy 

- large and small vessel disease 

 

Vascular Foot

 

A.   Large Vessel Disease

 

Different disease pattern to non-DM population:

- younger onset

- more rapidly progressive

- above and below knee (non-DM below knee rare)

- typical location at or just distal to popliteal vessels

- more diffuse with longer occlusions       

           

Symptoms

- vascular claudication

- rest pain

- nonhealing or hindfoot ulcer

  

B.  Small Vessel Disease

 

Microangiopathy

- primarily responsible for retinopathy / nephropathy

- may contribute to delayed ulcer healing

 

Immunopathy

 

Good BSL control improves healing  (less microbial growth;

no impaired chemotaxis)

 

Nutrition affects wound healing; predictive indices 

- total protein > 6 g/dl or 60 g/L

- albumin > 3.5 g/dL or 35 g/L

- lymphocyte count > 1500 /mm3

- transferrin < 200mg/dl

 

Diabetic Foot Complications

1)   Diabetic Foot Ulcers (DFU)

2)   Diabetic Foot Infections

3)   Charcot Arthropathy (refer to separate section)

 

1. Diabetic Foot Ulceration (DFU)

 

Rule of 50s -

50% DM admissions 

50% of all leg amputations

50% involve major level (BKA or AKA)

50% coexisting vascular disease

50% contralateral amputation 5 years

50% mortality 5 years (higher than breast and prostate ca)

 

85% of diabetic amputations involve DFU

 

2. Diabetic Foot Infection

 

Microbiology

 

1) Acute & Mild Infections

- usually monomicrobial

- commonly S Aureus, Strep

- Up to 30% of DFU hospitalized patients MRSA  

 

2) Chronic & Severe

- more likely polymicrobial

- G + Cocci (Staph; Group B Strep)

- G - (E Coli; Pseudomonas)

- Anaerobes –in ischaemic Limbs; Eg Bacteriodes Fragilis

 

Workup of Diabetic Foot 

 

Diabetic Foot History

 

Ulceration 

- duration 

- episodes of infection

- mobility level 

- prior treatments (wound care; shoe-wear) 

 

Diabetic Control

- HbA1c

- end organ disease (vascular; cardiac; retinopathy; neuropathy; nephropathy)  

 

Examination

 

Look 

- shoes – fit, material, wear-pattern

- bony prominences / deformity

- ulcers

   size, depth, granulation tissue, deep structures, cellulitis

- toenails - ingrown, thickened (vascular/ fungal)

 

Feel 

- pulses / capillary refill

- temperature (Charcot)

 

Move 

- anterior and lateral compartment mm power (for balancing transfers)  

 

Special Tests 

- Silfverskiold Test (need for TAL) 

Diabetic Amputations

Risk FactorsToe gangrene

- DM > 10 years

- chronic hyperglycaemia

- impaired vision or joint mobility

- lack education

- increasing age

- previous amputation

 

Considerations

- blood flow

- soft tissue envelope

- deformities / Charcot collapse

- sensation

- contractures - Achilles tendon, knee, toe

- rehab goals

 

Selection of Level

 

Aim is to preserve foot

- BKA leads to contralateral BKA in 1/2 in 5 years

 

'Biologic Amputation Level'

- most distal functional amputation level with reasonable potential for wound healing

 

Technique

 

No tourniquet

 

Cover with IV Abs 10 days then oral until wound healing

 

2 stage procedure

 

No sharp corners on bone

 

Long plantar flap if available 

- otherwise fish mouth

- tensionless flap

- sutures 8/52

- non constrictive dressings

 

Delay Weight bearing and prosthesis

 

Amputations

 

Toe

 

Try & leave base proximal phalanx

 

If complete toe amputation 

- proximal to metatarsal neck

 

Hallux

- must stabilise sesamoids or they retract & expose base MT

 

2nd toe 

- avoid because get severe hallux valgus

- may need to fuse 1st MTPJ

 

Ray

 

Most useful for 1st or 5th ray

- central ray resection takes a long time to heal if wound left open

- avoid multiple ray amputations 

- often difficult to close wounds after ray amputation & may need to leave open rather than close under tension

 

Fifth ray 

- racquet for toe and then straight lateral

- preserve base of fifth (P brevis)

 

Transmetatarsal amputation 

 

Good 

- toe filler only, no shoe modification

 

A.  Lisfranc

- preserve base 5th MT

- leave PB attach

 

B.  Chopart

- reattach T Ant and T Post to neck of talus

- post op cast in dorsiflexion

 

Late equinovarus

- percutaneous TA lengthening

- 2 medial and one lateral

- in theory leaves more intact laterally

- +/- lateral transfer of Tibialis Anterior

 

Boyd 

 

Talectomy & calcaneotibial arthrodesis

- forward translation of the calcaneus

- similar flaps to Symes but longer

- Occasionally in children

- Poor in adults

 

Pirogoff 

 

Talectomy & vertical osteotomy of calcaneus 

- osteotomy thru midbody then forward rotation of calcaneum to appose tibial plafond

- good in kids, too long to unite / heal in elderly

 

Syme's 

 

Ankle disarticulation preserving heel pad

 

Advantages

 

1.  Able to go to toilet in night without prosthesis

- can ambulate short distances if need

 

2.  Bulb makes the socket self suspending

 

Disadvantages

- cosmetically poor because stump is very wide 

- many women unhappy with cosmesis

 

Partial Calcanectomy 

 

Indication

- for non-healing heel ulcers associated with vascular insufficiency 

- not so severe that wound won't heal

 

Technique

- ulcer excised & longitudinal incision proximal & distal

- T Achilles reflected

- all of posterior process of calcaneum excised

- this makes skin closure easy

- T Achilles can't be reattached & is left free

- patient must wear rigid AFO style partial foot prosthesis with cushion heel long term

 

Trans-tibial 

 

Long posterior flap now standard

- previously always 6 inches from knee joint but trend now is to make as long as possible 

- avoid distal 1/3 as poor soft tissue coverage & padding

 

Posterior flap length is equal to diameter of limb at level of bone cut plus 1cm

- fibula is cut 1-2cm shorter

- don't perform tibiofibular synostosis 

- usually get painful non-union 

- gastrocnemius myodesis 

 

BKA AP XrayBKA Lateral Xray

 

 

 

 

Investigations

 

Perfusion Estimation

 

1. ABI

 

Method

- use doppler US & BP cuff

- systolic BP at ankle & arm

- ABI = Ankle / Brachial

 

Normal Range

.9 – 1.3

 

Measurement in DM

- may be falsely elevated due to calcification of media

- “trusted when low but not high”

- <.9 suggestive of PVD

- <.7 severe PVD

 

2. Transcutaneous O2 Measurement  (TcPO2)

 

Measured by electrode placed on warmed foot

- affected by oedema/ infection / neuropthy

- <25 mmHg = unlikely to heal

 

3. Toe Blood Pressure

 

Measured by plethysmography

- >30 mmHg = good wound healing potential

- Less sensitive / specific than TcPO2

 

 Angiogram

 

 If foot pulses are absent / asymmetric

 

Osteomyelitis Imaging

 

1. X-Ray

 

- may not show changes in early stages (<14 days)

- later Stages - Triad– Osteolysis, periosteal reaction, bone destruction

 

2. MRI

 

Most sensitive imaging for diabetic foot infections

 

Findings    

- bone oedema

- abscesses (Low Signal T1; Gad Ring enhancement)

Management

Aim

 

Stable, shoe-able plantigrade foot

 

Multidisciplinary approach

 

Multidisciplinary foot clinics (MDFC) 1st established UK 1980s

- shown to significantly reduce rate of diabetic amputations

- involve:

 

Endocrinologist +/- diabetic nurse

- glycaemic control crucial

 

Podiatrist

- non-surgical debridement

- orthoses

  

Orthotist / Plaster tech

 

Vascular surgeon

- referral if absent or asymmetrical pulses

 

Orthopaedic surgeon

- TCC

- foot reconstruction; amputations

 

Infectious Disease Consultant

- infected / nonhealing ulcers

 

Diabetic Foot Care

 

Foot Hygiene

- daily wash with mild soap & warm water

- powder between toes & moisturiser to ankle

- plain cotton socks inside out (2 socks ↓shear)

- minimum tds inspection

- report immediately all blisters / ulcers & unilateral warmth / swelling (Charcot’s fractures)

- no walking barefoot

 

Shoes / Orthoses

- custom made orthoses and shoes reduce DFU recurrence 1

- shoes should be

wide/ deep/ round toe box

soft leather (hard materials irritate)

adjustable

no/low heel

 

Issues

 

Infections

Ulcers

Charcot

Fractures

 

1.  Diabetic Foot Infections

(Therapeutic Guidelines; Version 15; 2015)

 

A.  Mild Cellulitis (+/- Ulcer)

 

Combination oral Abx

- Augmentin Duo Forte

OR Cephalexin PLUS Metronidazole 

OR Ciprofloxacin PLUS Clindamycin (Penicillin Allergy)

- offload ulcer (crutches, custom orthotics )

 

B.  Severe Cellulitis (+/- Ulcer)

 

IV Abs (Timentin or Pip-Taz; IV Cipro + Clind for Penicillin Allergy)

- Offload Ulcer

 

C.  Ulcer with Osteomyelitis

 

Diagnosis

- probe-to-bone test (Positive predictive value .57; Negative Predictive Value .98) 2

- plain films (low sensitivity; particularly early stage)

- MRI (high sensitivity and specificity; with plain films Ix of choice)

- Tc Bone Scan + Labelled WCC (if MRI contraindicated)

 

Management OM

- consider debridement & intra-operative deep MCS (more accurate)

 

Antibiotics

- broad spectrum initially / timentin or pip-taz

- adjust 2° to MCS

- ID consult

 

Diabetic Calcaneal Abscess

 

 

Diabetic Heel Abscess XrayDiabetic Heel Abscess MRIDiabetic Heel Abscess MRI 2

 

2. Neuropathic Ulcers

 

Diabetic Ulcer

 

 

Classification

 

1)Wagner Classification3

 

Most used classification for DFU in ortho literature

 

Grade 0      

 

Pressure area           

- Footwear Modification

 

Grade I      

 

Superficial Ulceration           

- local treatment, footwear modification

 

Grade II    

 

Deep Ulceration (probes to tendon / capsule)          

- TCC, footwear modification

 

Grade III   

 

Deep ulceration + secondary infection           

- debridement, antibiotics

 

Grade IV   

 

Partial foot gangrene

- Abx, amputation, hyperbaric O2

 

Stage V    

 

Whole foot Gangrene

- regional amputation, Abx

 

2) University of Texas4

 

Each wound has a grade and stage

- increasing stage, across all grades, more predictive of amputation & prolonged healing time

- UT better prognosticator than Wagner

 

Grade 1 Preulcerative

Grade 2 Superficial Wound

Grade 3 Deep wound penetrating to capsule or tendon

Grade 4 Deep penetrating to bone or joint

 

Stages A Clean

Stages B Nonischaemic Infected

Stages C Ischaemic Noninfected

Stages D Ischaemic Infected

 

Management

 

Nonoperative

 

1) Off-load 

TCC remains the gold standard

- other options: removable cast walkers; modified footwear

 

2) Increase healing rates

Hyperbaric O2 - short-term reduction ulcer size

Negative Pressure Wound Therapy (NPWT)

Biologic Therapy eg amniotic membrane (experimental)

 

Operative

1) Tendoachilles lengthening (TAL)

Aim to reduce forefoot pressures

 

Colen et al Plast Reconstr Surg 2013

- level 3 retrospective cohort

- 25% of patients with DFU & no TAL Vs 2% of DFU with TAL had recurrent ulcer

 

2) Gastrocnemius Recession

3) Toe Flexor Tenotomy

 

3.  Charcot Foot

 

See Charcot Foot

 

4.  Fractures in Neuropathic / Diabetic Feet

 

Principles

 

1.  Augment ankle ORIF

2.  Double time for sutures

3.  Double immobilisation period

- 12 weeks NWB

- 4-5 months in walking cast

4.  Brace for 1 year after surgery

- to prevent late Charcot arthropathy

- assume Charcot joint will develop

 

References 

1- http://www.ncbi.nlm.nih.gov/pubmed/22336901

2- http://www.ncbi.nlm.nih.gov/pubmed/17259493

3-  http://www.ncbi.nlm.nih.gov/pubmed/7319435

4- http://www.ncbi.nlm.nih.gov/pubmed/8986890

Foot Fractures

Chopart Dislocation

Background 

Francois Chopart (1743–1795)

French surgeon who described Chopart amputation 

 

Definition

 

Traumatic dislocation of TNJ or CCJ

 

Aetiology

 

High velocity injury

- MVA

- fall from height 

 

Crush Injury 

 

Management

 

Urgent Reduction

 

Assess stability

- K wire

- +/- primary fusion if joints severely damage

 

 

Cuboid Fractures

Types

 

1.  Capsular avulsions

 

2.  Body / Nutcracker fracture

 

Nutcracker fracture

 

Epidemiology

- rare

 

Mechanism

- forced eversion / abduction of forefoot

- cuboid crushed between 4th and 5th MT and calaneum

 

Pathology

- displaced cuboid fracture with subluxation of tarsus

- may interfere with peroneal tendons

- shortens lateral border of foot

 

Diagnosis

 

Oblique xray

- foot 30o medial

 

Management

- ORIF and bone graft

- rarely need bridging external fixation

 

 

March Fracture

 

Definition

 

Insufficiency fracture

- secondary to exceeding fatigue threshold

- usually of second or third MT shaft

 

Epidemiology

 

Onset of new and very intense / strenuous physical activity

- i.e. new army recruits / dancers

 

Women with postmenopausal osteoporosis

 

Association

 

Cavus feet

 

History

 

Pain after walking & then with walking

Swelling after activity

 

Examination

 

Tender swelling along MT shaft

 

Often visible dorsal swelling

 

X-ray

 

Initially normal

- may need oblique xray to diagnose

 

Second Metatarsal Stress Fracture

 

Later shows callus around fine transverse / oblique fracture

- usually midshaft or distal

- usually incomplete

- often 2nd or 3rd MT longer than 1st

 

Bone Scan / MRI

 

Show increased activity prior to xray changes

 

Second MT Stress Fracture Bone Scan

 

Management

 

Non operative

 

Symptomatic

- rest for 4-6 / 52

- MT dome

- may need strapping / cast / moon boot 

 

95% union rate

- complete fracture rare

 

Operative

 

Rarely required

 

Dorsal approach / plate / bone graft

 

Metatarsal Fractures

Metatarsal Fractures

 

Indications for Surgery

 

1.  Displacement > 4 mm

2.  Angulation > 10o

3.  Intra-articular

 

Base of 5th Metatarsal

 

Classification

 

Zone 1

- avulsion fractures

 

Base of fifth MT Fracture

 

Zone 2

- fracture at the metaphyseal-diaphyseal junction

- fracture closely akin to the injury described by Jones 

 

Fifth Metatarsal Undisplaced Avulsion Fracture5th Metatarsal Stress Fracture

 

Zone 3

- proximal diaphysis

- stress fracture of the proximal 1.5 cm of the shaft of the fifth metatarsal

- these fractures are not acute 

- always have prodromal symptoms or radiographic signs of repetitive stress injury

 

Base of 5th Metatarsal Fracture Zone 2Jones FractureJones Fracture 2

 

Zone 1

 

Definition

- tuberosity avulsion fracture

- usually extra-articular but may extend into cuboid-metatarsal joint

 

Aetiology

- Peroneus brevis contracture following inversion 

 

DDx

 

1.  Apophysis 

- smooth and longitudinal 

- appears F 9-11 M 11-14 

- can look displaced or fragmented

- fuses 2-3 yrs after appearance

- apophysis does not enter cuboid-MT joint

 

2.  Os peroneum

 

3.  Os Vesalium

 

Os Vesalium

 

Non Operative Management

 

WBAT in moonboot

 

Randomised trial

- cast v soft dressings

- better outcome without cast

 

Operative indications

 

Displaced intra-articular fracture > 30% of articular surface / > 2mm step

- rare 

- aim to restore integrity of the cuboid MT joint

 

Surgery

- open / closed reduction with pinning/screws

 

Zone 2 

 

Definition

- transverse fracture of 5th MT shaft 1.5cm from base 

- at diaphysis / metaphysis junction

- goes into the 4th/5th MT joint

 

Aetiology

- adduction to forefoot

 

Non Operative

 

Undisplaced fracture

- NWB for 6-8/52

- xray healing occurs from medial to lateral

- lags behind clinical healing by weeks to months

- lack of clinical healing after 8-10/52 NWB is not unusual

- consider continued protection / cast immobilisation / surgery at that time

 

Quill OCNA 1995

- 1/3 went on to re-fracture

- argument for early surgery

 

Operative 

 

Indications

- displaced / athlete / non union

- 50% either do not heal primarily or refracture

 

Options

- IM screw / TBW / plate +/- bone graft

 

Zone 3

 

Definition

- diaphyseal stress fracture

- distal to 4/5 MT joint

- secondary to repetitive distraction force

 

X-ray

- cortical hypertrophy, narrowing medullary canal & periosteal reaction

- prolonged immobilization often required

- may take 20/52

 

CT

 

 

Management

 

NWB initially

 

Competitive athlete 

- bone graft & IM screw +/- USS

- NWB 6/52

 

Lareau et al Foot Ankle Int 2016

- 25 NFL players with acute Jones fracture

- Jones specific screw with BMAC from iliac crest

- average RTP of 8.7 weeks

- 12% refracture requiring revision surgery

 

Jones Screw 2

 

 

Surgical technique

- shaft of 5th MT is not straight

- entry point is high and medial to get straight shot

- may need to sequential increase cannulated drill size

- Jones specific screws 4.5, 5.5, 6.0 with low profile heads

 

Neck of 5th / Shaft metatarsal fractures

 

Fifth Metatarsal Neck Fracture

Navicular fractures

Types

 

1.  Dorsal lip fracture / Tuberosity fracture

- avulsion fractures

- most common

- beware avulsion T post

 

2.  Body fracture

 

3.  Stress Fractures

 

Body Fractures

 

Types

 

A.  Transverse fracture in coronal plane

B.  Transverse from dorsolateral to plantarmedial

C.  Central or lateral comminution

 

Displaced Navicular FractureDisplaced Navicular Fracture

 

Management

 

ORIF if displaced

- aim to restore TNJ

- 70% satisfactory reduction

 

Complications

 

Stiffness

- lose some inversion / eversion as part of STJ

AVN 30%

OA

 

4. Stress fracture

 

History

 

Pain

No distinct trauma

 

Xray

 

Navicular Stress Fracture

 

CT

 

Navicular Fracture CT

 

Issue

 

Can go on to displaced nonunion

 

Navicular Stress Fracture DisplacingNavicular Stress Fracture Nonunion

 

Management

 

1.  Strict NWB in boot

- consider bone stimulator

 

2.  ORIF and graft

- if >50% of width of bone and failure of non-operative management

 

Navicular Stress Fracture UnionNavicular ORIFNavicular ORIF Union

 

 

 

Foot Tumours

Benign Bone Tumours

1. Giant cell tumour

 

Often present with a painful swollen area, lytic on X-ray

- calcaneus > talus

- rare in skeletally immature

- curettage and grafting

- local recurrence ~50 %

- may need to bone graft defects

 

2. Osteochondromas

 

Can occur in foot and ankle

- single or multiple

- simple excision at base

- malignant transformation very rare in foot

 

Subungal exostosis 

- under the toenail (esp 1st)

 

3. Osteoid osteoma

 

Especially in hindfoot

- difficult to diagnose on x-ray

- CT / MRI / bone scan

- excision / RF ablation (CT guided)

 

Osteoid Osteoma 2nd Toe Bone ScanOsteoid Osteoma 2nd Toe CTOsteoid Osteoma 2nd Toe MRI

 

4. UBC

 

Infrequent in foot

- calcaneum

- UBC can become symptomatic from stress fractures

- treat with curettage and BG

 

5. ABC

 

Originate in metaphyseal bone

- MT most common foot site (also calcaneus)

- treat with curettage and BG / excision

 

Foot Aneurysmal Bone CystFoot ABC MRIFoot ABC Excision and Autograft

 

 

Benign Soft Tissue Tumours

Assume all malignant until proven otherwise

 

1. Ganglion

 

Foot GanglionAnkle ganglion MRI

 

Mucoid degeneration of a joint capsule or tendon sheath

- may fluctuate in size or disappear

- firm subcutaneous nodule

- may be painful, especially if compressed

- often transilluminate

 

Treatment

- observe

- multiple aspirations / cortisone injections

- surgical excision

 

Surgical excision

- need to find neck

- may arise from AKJ / STJ / T post tendon

- tie off neck or excise segment of capsule

 

Foot Ganglion 1Foot Ganglion 2Foot Ganglion Neck 1

 

Foot Ganglion Neck 2Foot Ganglion Neck 3

 

2. Plantar fibromatosis

 

Most common soft tissue tumour in the foot

- see other notes

 

3. Fibroma

 

Discrete nodule of well differentiated fibroblasts

- on sole or dorsum

- slow growing

- pain uncommon

- usually subcutaneous, firm, not attached to skin

 

Treat

- local excision if required

(recurrence rare)

 

DDx

- Fibrosarcoma

- Plantar fibromatosis

 

4. Giant cell tumour of the tendon sheath

 

Ankle Giant Cell TumourAnkle Giant Cell Tumour

 

Usually in tendon adjacent to ankle (can be anywhere)

- well defined firm nodule with an obvious capsule

- not always painful

- pain with direct pressure

 

Treatment

- observe (may involute)

- surgical excision (recurrence rare)

 

5. PVNS

 

Common around the ankle or midfoot

- may involve multiple bones

- usually in young adults

 

X-ray

- may show bony erosions

- brown villonodular synovium

 

Treatment

- excision include complete synovectomy

- recurrences common but not all symptomatic

- DXRT if severe

 

6. Lipoma

 

Most common on dorsum

- subcutaneous

- soft feeling / mobile / grape like

- painless unless compressed

 

Treatment

- marginal excision

(local recurrence rare)

 

7. Neurilemmoma

 

Benign schwannoma

- well encapsulated solitary tumour

- originates from nerve sheath

- slow growing

- nerve fibres spread over its surface

- painful if compressed or causes compression

 

MRI

- hyperintense rim on T2

 

Management

- separate nerve fascicles

- excise neurilemmoma

- marginal excision

- attempt to preserve normal nerve fibres

 

8. Neurofibroma

 

Singular or multiple

- extend along course of the nerve 

- 1/2 not associated with NF

 

Often local pain especially with compression

- may affect distal nerve function

- malignant change rare in solitary lesion (occurs with NF)

 

MRI

- target sign

- can be seen with neurilemmoma

 

Treatment

- tumour arises from within the nerve

- excision usually cause further loss of function

 

9. Solitary Hemangioma

 

Present with episodes of dependent swelling

- often after local trauma

- diffuse edges / can be difficult to palpate

 

Diagnose on MRI

- hyper-intense on T2 FS

 

Treatment

- only needs excision if limits function

- often incomplete - recur

 

10. Glomus tumour

 

Presents as painful toe, sensitive to cold

- pain with local pressure

- usually subungual

 

X-ray

- may scallop adjacent bone on x-ray

 

Treatment

- marginal excision for pain

Malignant Bone Tumours

1. Osteosarcoma

 

Second / Third decade, M>F

- calcaneal

- diagnosis often delayed

- treat with radical resection

 

2. Chondrosarcoma

 

Middle age or older

- slow growing

- malignant change of osteochondroma / enchondroma

- treat with wide / radical resection

 

3. Ewing's

 

Lytic expansile mass in a MT

- can be anywhere

- Treat with wide resection / chemo / DXRT

 

4. Metastatic Tumours

 

Infrequent

- <1% all bony metastases

- often lung

- often below the diaphragm (i.e. ovarian)

 

Malignant Soft Tissue Tumours

Epidemiology

 

Most common malignant tumour

- malignant melanoma

 

Most common sarcoma

- synovial sarcoma 50%

- consider it for every foot lump

- most in dorsum and hindfoot

 

Foot and ankle considered single compartment

- Enneking staging

- unless tumour confined to singe ray

 

1. Synovial Sarcoma

 

Consider it for every foot lump

 

Diagnosis often delayed

- varied presentation

- slow growing firm fixed mass

- indolent course

- small latent mass with period of rapid growth

- rapidly growing mass

- painful (even before mass) or painless lump

 

Peak incidence 20-50

 

Spread via lymphatics (rare for sarcoma)

 

X-ray

- soft tissue mass (+/- Ca++)

 

MRI

- aggressive on appearance

 

Prognosis

- size can predict outcome

 

Treatment

- wide / radical excision +/- DXRT

- ? role of chemotherapy

 

2.  Malignant melanoma

 

Common in  the foot

- often in junctional naevi

 

Treatment

- wide excision

- depth of lesion most important prognostically

- assess lymph nodes

 

3. Subungal melanoma

 

Less aggressive than other MM

- present with loss of the nail

 

DDx

- haematoma

- mark nail with knife

- return 2 weeks later

- if melanoma the pigment will be in same position and the mark on the nail will be distal

 

Treatment

- toe amputation

- assess lymph nodes

 

4. Clear cell sarcoma

 

Highly malignant

- common in foot and ankle (43%)

- usually 2nd/3rd decade

- wide excision +/- chemotherapy

 

5. Epithelioid sarcoma

 

Innocuous nodule on the dorsum of the foot in young adults

- wide  / radical excision

- lymphatic & haematogenous spread

 

6. Hemangioendothelioma

 

Vascular tumor in bones or soft tissue

- any age

- multiple on same extremity

- wide excison +/- DXRT

- long follow up for all

- difficult to predict which will behave aggressively

 

7.  Acral Myxoinflammatory Fibroblastic Sarcoma

 

DDx ganglion, GCTTS, tenosynovitis

- low grade

- don't metastasise but can recur locally

- marginal excision

 

8.  Fibrosarcoma

 

Prognosis depends on histological grade

- wide / radical excision

- in childhood need less aggressive treatment

 

 

 

 

Plantar Fibromatosis

Definition

 

Fibrous proliferative lesion in plantar fascia

 

Epidemiology

 

Male, white, middle age

 

May arise in isolation

 

Association Dupuytren's Diathesis

- aka Lederhosen disease

 

Pathology

 

Proliferative Fibroblastic lesion

- May resemble fibrosarcoma histologically

 

Histology

 

Heavy strands of relatively acellular mature collagen

 

Enneking 3 Stages

- proliferative phase

- involutional (active) phase 

- final (residual) phase

 

History

 

Present with lump in foot

 

Often painless

- unlike Dupuytren's there is no inflammatory proliferative phase

- asymptomatic through growth

 

Examination

 

Tender subcutaneous nodule found in the medial half of the middle plantar fascia

- rarely causes contracture

 

DDx

 

Ganglion cyst

Neurofibroma / neurilemmoma

Fibrosarcoma / any of the other sarcomas

 

Rheumatoid nodule

 

Melanoma

Sweat gland carcinoma

 

MRI 

 

Useful

- T1 - low SI

- T2 - low or medium SI

 

Management

 

Non Operative

 

Observe if not symptomatic

 

Symptomatic

- padded shoes and orthoses

- transfer weight away

 

Operative

 

Indications

 

1.  Relieve associated symptoms from local extension & invasion

- may invade NV structures

2.  Pain when weight bearing

 

Problems

 

May recur after excision

- usually after incomplete / simple excision

- can recur & become locally invasive

- doesn't metastasise or become locally destructive

 

Technique Wide resection

 

Position

- prone

- tourniquet

 

Incision

- S shaped

- avoid 1st MT head

- avoid weight bearing arch

- minimise disruption of blood supply

- usual medial longitudinal incision interrupts most of the arterial supply to the skin beneath the longitudinal arch

 

Block resection of plantar fascia 

- 2 cm normal fascia proximal and distal

- entire width

- lateral plantar nerve is adherent to fascia on lateral side

 

Recurrence 

 

Consider radiotherapy

 

 

Great Toe

Dislocation

Epidemiology

 

Uncommon

- dancers

- athletes

 

Aetiology

 

Hyperdorsiflexion of the MTPJ

 

Pathology

 

MT head dislocates plantar

- may buttonhole through capsule

- can prevent closed reduction

 

Blocks to Reduction

 

1.  Sesamoids

2.  Conjoint tendon

3.  Intersesamoid Ligament

 

Management

 

Closed Reduction

 

Open Reduction

 

Dorsal Approach

- protect dorsal superficial nerve

- divide capsule medial to EHL

- may need to divide intersesamoid ligament

- may need to divide adductor hallucis

 

 

 

Hallux Rigidus

Definition

 

Painful restriction of dorsiflexion of the great toe 

- secondary to degenerative changes in MTPJ

- initially pain and synovitis

- osteophytes don't form medially or on plantar aspect

 

Epidemiology 

 

Two peaks

1.  Adolescence F > M

2.  Middle Age M > F

 

Aetiology

 

Often Idiopathic

 

Trauma

- OCD

- hyperextension injuries

 

Anatomical

- pronated foot

- abnormally long 1st MT

- pes planus

- DF 1st ray

 

Inflammatory

- gout

- CPPD

- inflammatory arthropathy

 

History

 

Pain on walking

- especially slopes & rough ground

- pain may become continuous

 

Numbness 

- compression of dorsomedial cutaneous nerve

 

Examination

 

Shoe shows excessive lateral wear

- toe off on lateral border 

- patient avoids dorsiflexion

 

Look

- hallux is usually straight

- MTPJ is enlarged

 

Feel

- synovial thickening

- palpable dorsomedial osteophyte & bunion 

- altered sensation dorsal toe / due to tethering of dorsomedial nerve by osteophytes

 

ROM

- DF restricted & painful N = 90°

- PF often reduced and painful N = 30°

 

X-ray

 

Changes of osteoarthritis

- dorsomedial osteophyte

- joint space narrowing

 

Great Toe Dorsal OsteophyteHallux Rigidus Dorsal Osteophyte

 

Management

 

Non Operative

 

Options

 

Education & Reassurance

 

Orthotics

- initially stiff soled shoes

- rockerbottom sole

- high toe box

 

NSAID

HCLA

 

Operative

 

1.  Moberg Osteotomy

 

Indication

- young patient with mild OA & > 30° PF

 

Technique

- dorsal closing wedge osteotomy of P1 

- converts PF range into functional DF

 

2.   Cheilectomy

 

Mann 1988 JBJS

 

Concept

- removal of dorsal osteophytes

- increase painless DF range (average 20°)

 

Great Toe Cheilectomy

 

Indication

- for adults with minimal degenerative changes

- normal joint space in plantar half MTPJ

 

Disadvantage

- recurrence of pain

 

Technique

- dorsal incision over MTPJ

- joint incised either side EHL

- synovectomy

- remove ~ 1/3 of dorsal MT head

- remove osteophytes from base of P1

- need DF of ~ 90°

- stiff shoe till ROS

- then flexible sole and ROM exercise

 

3.  Arthrodesis

 

Great Toe MTPJ OAGreat Toe MTPJ Fusion APGreat Toe MTPJ Fusion Lateral

 

Indication

- adults with significant degenerative changes

 

Disadvantage

- lateral transfer metatarsalgia

- IPJ OA

- malposition

- limitation of footwear type

- non-union

 

Technique

- dorsomedial approach

- protect dorsal cutaneous nerve

- mobilise EHL laterally and open capsule

- divide collaterals

- free P1 of soft tissue attachments

- 15° valgus

- 15° DF relative to plantar surface / 20 - 25° relative to metatarsal shaft

- dorsal plate / crossed screws

 

Results

- 30% develop asymptomatic OA IPJ

 

Hallux Rigidus Fusion 2 screws APHallux Rigidus Fusion 2 screws Lateral

 

4.  Interpositional Arthroplasty

 

Indication

- severe OA & moderate demand

- minimal bone resection

 

Technique

- imbricate dorsal & volar capsule into joint space

 

5.  Swanson Arthroplasty

 

Indication

- adults with low demands

 

Disadvantage

- breakage

- silicon synovitis

- very difficult to salvage

 

6.  Keller's Procedure

 

Indication

- for elderly with low demands

 

Disadvantages

- lose windlass mechanism

- transfer metatarsalgia

- cosmetically poor

- drifts into both DF & valgus / Cock Up deformity

 

 

Hallux Valgus

Background

DefinitionHallux Valgus Severe

 

Bunion

- medial prominence of head of 1st MT

 

Hallux Valgus

- medial deviation 1st MT

- lateral deviation of great toe

 

Anatomy

 

Metatarsal head

- has 2 grooves separating ridge (cristae)

 

Sesamoid

- in each tendon of FHB

- sesamoids attach to P1

- no attachment to MT head

- sesamoid ligaments attach to sesamoids and plantar plate

- FHL passes plantar to the plate & between the sesamoids

 

Plantar plate

- formed by

- FHB / Abd. Hall / Add. Hall / Plantar aponeurosis /  capsule

 

Sesamoids and plantar plate stabilised

- abductor hallucis (medial)

- adductor hallucis & trans metatarsal ligament (lateral)

- insert into sesamoids & Base P1

- no muscles insert into head MT

 

Collateral ligaments

- from head of MT to base of P1

- insert into sesamoids

 

Biomechanics

 

Great Toe provides stability to the medial aspect of the foot

 

Windlass mechanism of plantar aponeurosis

- plantar aponeurosis arises from tubercle of calcaneum

- medial slip inserts into base of proximal phalanx via sesamoids

- as body passes over foot, P1 forced into DF & slides over MT head

- plantar aponeurosis winds around MT head & plantarflexes the 1st MT

- creates arch

 

In hallux valgus, windlass is less effective

- results in transfer of weight to lateral aspect of foot

- especially second MT head

 

Blood Supply

 

3 main

- 1st dorsal and plantar metatarsal artery

- superficial branch of medial plantar artery

 

Medial

 

Medial plantar artery

- remains plantar to the MT until the level of the neck when it runs obliquely dorsally

- divides into the medial cervical branch, and the medial sesamoid branch

 

Lateral

 

First plantar MT artery

- is formed by the deep plantar arch and a perforating branch from the DPA

- runs distally in the 1st MT space

- nutrient artery to neck (variable)

- cervico-sesamoid branch (constant)

 

Lateral Cervical branch

- enters plantar surface at base of neck

- supply major part of head

- care in not stripping under the neck to preserve the cervical branch

 

Dorsolateral

- small branch from DPA

- penetrates the dorso-lateral capsule near margin of  articular cartilage

- not big enough to provide sole supply

- can be sacrificed if needed

 

Characteristics

 

Great toe

- lateral deviation of the great toe  (HVA > 15o)

- medial deviation of the first metatarsal  (IMA > 9o)

- +/- subluxation of the first MTPJ

- hallux pronation

- prominent mediation eminence

- sesamoid rotation / uncovering

 

Lesser toes

- overriding of the second toe

- metatarsalgia

- lesser toe hammer & claw

 

Epidemiology

 

Two ages of presentation

 

1.  Adolescent form

- usually bilateral

 

2.  Adult form ~ 50's

- strongly familial

- positive FHx in 2/3

- F > M

- F:M = 9:1 in those needing operations

 

Aetiology

 

Likely multifactorial

 

1.  Shoe Wearing

 

Evidence

- more women are affected

- women's shoes are tight-toed

- unshod 2% vs 33% shod

- unshod toes separate on weight bearing

- in shoes, toes crowded & hallux abducted

 

2.  Hereditary

- usually strong FHx

- tend to present earlier

- AD with incomplete penetrance

- made worse by female's shoe wear

 

3.  Generalised Ligamentous Laxity

- splaying of forefoot

- excessive mobility of 1st TMT

- laxity of medial capsule of MTPJ

 

4.  Anatomical factors

 

Metatarsus Primus Varus

- associated with HV

- especially adolescent variety

 

Metatarsus Varus

 

1st MT

- long / short

- hyper pronated

 

2nd Toe amputation

- loss of lateral support for great toe

 

MTPJ

- rounded joint

 

TMTJ

- hypermobile

- medially slanted

 

Flatfoot

 

Short achilles tendon

 

5.  Pathological Conditions

 

Rheumatoid arthritis

- leads to loss of capsular support

- RA best treated with fusion

 

Neurological conditions

- CP best treated with fusion

 

Pathology

 

A.  Congruent MTP joint

 

Cause

- increased DMAA 

- Hallux valgus interphalangeus

 

Present

- enlarged medial eminence (bunion)

- pressure against shoe

- painful bursa or cutaneous nerve

 

Management

- MTP joint usually stable & won't sublux

- can’t do distal soft tissue release

- will sublux a congruent joint

 

B.  Incongruent MTPJ

 

Hallux Valgus Incongruent Joint, ex

 

Subluxed MTPJ

- usually progressive

 

Origin

- starts with lateral pressure on great toe

- tight high heels

- P1 moves laterally

 

Progression

- PI moves laterally & puts pressure on MT head

- moves it medially, thus increasing intermetatarsal angle

- attenuation of medial joint capsule

- sesamoid sling held in place by ADDH & transverse metatarsal ligament

- MT head moves further medially / varus deformity

- slides off sesamoids

 

Final deformity

- appearance of lateral migration of sesamoids

- however sesamoids maintain constant distance from second MT

- lateral sesamoid lies beside MT head in intermetatarsal space

- ADDH pronates the great toe

- medial extensor hood / capsule stretched

- EHL & FHL comes to lie lateral to MTPJ

- finally, lateral capsular structures become contracted & the deformity becomes fixed

 

C.  Medial Eminence

- MT head changes occur

- groove or medial sagittal sulcus develops at medial border of articular cartilage

 

D.  Bunion

- callosity of skin + bursa

 

E.  Lesser Toes

- MTP less stable & weight transferred to MT 2 & 3 -> callosities

- great toe may drift beneath 2nd toe

- alternatively, 2nd toe may subluxate laterally

- lateral toes become crowded

- often develop claw or hammer deformity

- increased weight bearing through middle MT heads may lead to metatarsalgia

- worse with clawing of lesser toes

 

History

 

Pain

- over medial eminence (75%)

- metatarsalgia under lesser toes

- degeneration of sesamoid joint

- dorsal aspect osteophytes / rigidus

 

Shoe problems

- wide foot

- difficulty fitting shoes

 

Secondary deformity of lesser toes

- especially hammer deformity of the second toe

- rubbing of the PIPJ on shoe

 

Cosmetic appearance

 

Examination

 

Hallux Valgus Clinical

 

Standing

- bunion

- HV

- clawing / hammer toes

 

Assess ROM ankle and STJ

- tight T Achilles

 

Look at wear patterns on foot

- callosities under 2/3 MT head

 

MTPJ

- tender bunion

- painful MTJP

- correctable / ROM correctable

- pain over sesamoids

 

TMTJ

- hypermobility

- > 9mm abnormal

 

Lesser toes

- deformity / correctable

 

Neurovascular examination

           

Weight Bearing AP X-ray

 

1.  Hallux Valgus Angle / MTPA

- metatarso-phalangeal angle

- normal < 15o

 

Hallux Valgus MTPA > 40

 

2.  Intermetatarsal angle/ IMA

- normal < 9o

 

Hallux Valgus Intermetatarsal Angle > 20 degrees

 

3.  Congruence

- place dots

- medial & lateral edges of the articular surfaces of the MT head & P1 base

- assess to see if line up / joint congruent

 

Hallux valgus Incongruent Joint

 

4. Interphalangeal angle

- normal is <10°

- identify hallux interphalangeus

 

5.  DMAA

- distal metatarsal articular angle

- normal < 6o

 

Hallux Valgus Increased DMAA

 

5.  Sesamoid subluxation

- amount of lateral sesamoid uncovered by MT

- medial sesamoid should not cross midline axis of MT

 

Hallux Valgus Lateral Sesamoid Uncovered

 

6.  MTPJ OA

 

7.  Size of the medial eminence

- amount of MT head medial to the line along the medial border of the MT

 

8.  TMT Angle

- medial sloping

 

Hallux Valgus Medial Sloping TMTJ

 

Mann Classification  

 

1.  Congruent

 

2.  Incongruent

 

A.  Mild

 

MTPA < 30°

IMA < 15°

Lateral sesamoid < 50% uncovered

 

Hallux Valgus Mild

 

B. Moderate

 

MTPA 30 - 40°

IMTA 15 - 20o

Lateral sesamoid 50 - 75% uncovered

 

C. Severe

 

MTPA > 40°

IMTA > 20°

Lateral sesamoid > 75% uncovered

 

Hallux Valgus Severe Unilateral

 

3.  Degenerative

 

Hallux Valgus Severe Degenerative

 

Management

Non-Operative

 

Education regarding shoe wear

- extra wide / large toe box

 

Insoles

- longitudinal arch support

- pre MT dome for metatarsalgia

- podiatry to attend to callosities

 

Toe spacers

 

Analgesia

 

Operative

 

Indications

 

1.  Continued pain and discomfort

2.  Difficulties with shoe wear

- split size shoe requirements 

- difficulty fitting shoes

- only 60% wear "fashionable" shoe post-op

3.  Deformity of lesser toes

4.  Skin problems

5.  Cosmetic appearance – relative indication

 

Contra-indications

 

Poor peripheral arterial circulation

Current sepsis

Uncontrolled diabetes

Peripheral neuropathy (relative)

 

Aims

 

1. Correction of the hallux valgus and intermetarsal angles 

2. Creation of a congruent MTP joint

3. Sesamoid realignment

4. Removal of the medial eminence

5. Retention of functional range of motion of the MTPJ

6. Maintenance of normal weight bearing mechanics of foot

 

Surgical Options

 

Congruent

 

1. DMAA  < 15°

- treat hallux interphalangeus

- Akin with exostectomy

 

2. DMAA > 15°

- Chevron with closing wedge

 

Incongruent

 

Mild

- Chevron

- DSTP (Distal Soft Tissue Procedure) +/- proximal osteotomy

 

Moderate

- DSTP & proximal osteotomy

- Scarf

 

Severe

- DSTP & proximal osteotomy

- arthrodesis

 

Rheumatoid

 

Mild to Moderate / Low demand

- arthroplasty

 

Severe

- arthrodesis

 

Hypermobile TMTJ

- fusion (Lapidus) & DSTP

 

Surgical Procedures

 

1.  Chevron

 

Hallux Valgus ChevronGreat Toe Chevron

 

Indications

- incongruent joint

- HVA < 30o / IMA < 15o

- patient < 60 years

 

Technique

 

Avoid lateral release = AVN 40%

 

Approach to Hallux Valgus

 

Dorsomedial approach in internervous plane

- don't go directly medial as will get sensitive scar

- protect dorsal sensory nerve

- distally based "V" capsular flap

- expose MTP joint

 

Exostectomy

- remove medial eminence with saw

- leave 1- 2 mm medial to medial sulcus

- otherwise risk hallux varus

 

60° osteotomy apex distal

- longer plantar limb to avoid sesamoids and inferior joint surface

- apex 1 cm from articular surface

- translate 5mm

- 1mm displacement corrects IM angle 1º

- can perform medial closing wedge to correct DMMA

 

Fixation

- not always necessary

- sutures / k wire / screw

 

Closure

- imbricate capsule

- advance to tighten medially

 

Second toe releases as needed

 

Post op

- bandage / POP to maintain correction

- check wound at 1 week

- bunion boot / heel walk

- toe spacer

- 6/52

 

Hallux Valgus Toe Spacer

 

Results

 

GE 75% if IMA >12° 

GE 95% if IMA <12°

 

Complications

 

AVN is rare

- ensure apex 8-10 mm from articular surface

- avoid DSTP

 

2.  Distal Soft Tissue Procedure

 

Hallux Valgus Pre DSTPHallux Valgus Post DSTP

 

Modified McBride

- release of tight lateral structures (ADDH, lateral capsule, transverse MT ligament)

- medial exostectomy (just medial to sagittal sulcus)

- medial capsular plication

 

(Modification: no longer excise sesamoid)

 

Indications

- mild HV with incongruent joint

- severe HV when combined with proximal osteotomy

 

Technique

 

1.  Dorsomedial approach

- protect nerve

- V shaped capsulotomy

- remove medial prominence

 

2.  Incision first web space

- protect branches of DPN

- insert lamina spreader

- release ADD hallucis at P1

- cut capsule between sesamoid and MT

- divide transverse MT ligament



Results

 

92% good results

 

Complications

 

Nerve injury

- plantar cutaneous nerve

 

Hallux varus

- from releasing lateral FHB from sesamoid

 

3.  Proximal Osteotomy + DSTP

 

Indications

- severe HV

- correct IMA with osteotomy

- correct HVA with DSTP

 

Results

- in combination with DSTP

- GE 90 %

 

Options

- crescentertic

- opening wedge (lengthens)

- closing wedge (shortens)

 

Opening wedge

- extend medial incision

- incomplete ostetomy with saw at base MT

- use bone from bunionectomy to fill gap

- fixation with small plate

 

4.  Scarf

 

Indications

- moderate HV

- see separate technique

- technically challenging but good results

 

5.  Akin

 

Indications

- congruent joint

- DMAA < 15o

- hallux interphalangeus > 10o

- residual HV after other procedures

 

Technique

- medial closing wedge osteotomy of P1

- combine with cheilectomy

 

6.  Keller Procedure

 

Technique

- resection 1/3 of proximal phalanx

- should use pin to stop cock up deformity & to stiffen joint

 

Indications

- housebound / non ambulator

- elderly

- salvage

- marginal circulation - DM / PVD

- hallux rigidus if cheilectomy or arthrodesis contra-indicated

 

Complications

- instability / cock up deformity

- transfer metatarsalgia (in young)

 

Results

- 80% good results

 

7.  Arthrodesis

 

Indications

- hallux valgus with arthritis

- severe hallux valgus

- neuromuscular disease i.e. cerebral palsy

- RA

- salvage procedure for failed procedures

 

Position

- 15º valgus

- DF 10º relative to plantar aspect of foot

- DF 30° relative to ray

 

Technique

- dorsomedial approach

- release EHB / mobilise EHL / release collaterals

- Coughlin male and female reamers

- secure with cross screws or plate

 

Hallux Valgus Arthrodesis

 

8. Lapidus Procedure

 

Hallux Valgus SevereHallux Valgus Proximal Osteotomy and Lapidus

 

Indications

- TMTJ hypermobility

- fusion TMTJ

 

Problems

- difficult to achieve union

- difficult to get position correct

 

Joint multiplanar

- malrotation poorly tolerated

- shortens medial column

- can get metatarsalgia

 

Technique

- slight plantar flexion and lateral deviation

 

Lapidus APLapidus Lateral

 

Complications of Surgery

 

Transfer Metatarsalgia

 

Recurrence

- incorrect surgery

- poorly performed surgery

- high risk groups i.e. adolescent

 

Nerve injury

- dorsal and plantar cutaneous nerve

 

Cock up Toe

 

Cause

- post Keller’s

 

Management

 

Arthrodesis MP joint

- shorten if don't use graft

- fusion rate 95% (BG) vs 70% (no BG)

 

Hallux Varus

 

Cause

- excessive medial resection

- resection of fibular sesamoid

- excessive lateral release or medial plication

 

Clinical

- not always painful

- cosmetically unacceptable

- difficulties with shoe wear

- cockup deformity

- with time stiffens in extension & medial deviation

 

Options

- soft, well fitting shoe

- arthrodesis

- soft tissue reconstruction

 

EHL Reconstruction           

- lateral two thirds of the tendon removed from its insertion

- detached distally, passed under transverse ligament

- inserted into proximal phalanx

 

AVN

 

Rarely seen in Chevron

- due to disruption of volar blood supply

 

Great Toe AVN Post Chevron

 

Management

- arthrodesis / excise avascular fragment and shorten toe

Scarf Osteotomy

Technique

 

A.  Longitudinal Cut

- plantar proximal / dorsal distally

- ends up being parallel to sole

- leave strong plantar portion of head to prevent dorsiflexion

- mark centre of head

- distally to a point 2mm prox and 3mm above the centre of the head

 

B.  Transverse cuts

- plantar proximal / dorsal distal

- angle of 45o with the long cut

- directed slightly proximal (10-15o) to aid displacement

 

Displacement

 

A. Transverse plane

- Primary direction of displacement

- can be up to ¾ of the surface as the strong lateral strut is preserved

- lateral rotation should be avoided as it increases the DMAA

- medial rotation can be used (to improve DMAA) but limits the amount of lateral displacement

 

B. Frontal plane

-  Lowering of the 1st MT head is achieved via the obliquity of the transverse cut

-  It will act to relieve metatarsalgia

 

C. Sagittal plane

- Lengthening can be done but tends to increase soft tissue tension and lead to stiffness

- shortening can be readily achieved by

- increasing the obliquity of the transverse cuts (max shortening 3mm)

- resecting ends of prox  / distal fragments (doesn’t elevate head as II to sole)

 

Fixation

 

Cannulated screws over K wires

 

A. Distal

- start lateral where the bone is string and allows medial resection

- aim obliquely into the MT head

- screw to end 2mm prox to cartilage

 

B. Proximal

- important to respect the lateral part of the fragment to avoid fracture

- aim transverse from dorso-medial to plantar-lateral

 

The corner is then taken off the proximal fragment 

- rounded with rongeurs where bunion has been sliced off

 

 

Ingrown Toe Nail

Onychocryptosis

 

Aetiology

 

Improper nail trimming

Tight shoes & socks

Poor hygiene

Repetitive trauma to distal toe

Curved nail bed in elderly

 

Stages

 

1.  Inflammation

- painful irritation about embedded nail plate in lateral groove

 

2.  Infection

- overt infection with granuloma & discharge 

- starts as serous discharge then purulent

 

3.  Granulation

- stage 1 & 2 + chronic changes

- hypertrophy of lateral wall

- growth of epithelium over chronic granulation tissue 

 

Management

 

Stage 1 

- non-operative

 

Stage 2 

- oral ABx then non-operative

- if fails partial nail avulsion

 

Stage 3 

- often requires partial nail matrix ablation

 

Non Operative

- warm saline soaks x2 /day

- pledget under nail corner

- cleaning of lateral groove

- nail will grow 2 mm /month

- aim for nail plate that protrudes distal to hyponychium

 

Operative

 

1.  Wedge resection

 

Technique

- remove lateral part of nail

- partial ablation of nail matrix

- debulk tissue in lateral fold

 

Post op

- non adherent dressings 48/24 then warm soaks

- open toe box shoe 10/7

- 3-4 weeks before normal shoes again

 

Complications

- recurrence spicules nail plate 

- 5%

 

2.  Zadek's

 

Technique

- removal of nail plate 

- removal of entire germinal nail matrix proximal to lunule

 

3.  Terminal Symes procedure

 

Technique

- amputation of the distal half of the distal phalanx

- good for dystrophic and mycotic nails

- toe end appears bulbous

 

 

 

Juvenile Hallux Valgus

Epidemiology

 

More common in girls

High incidence of positive family history (75%)

 

Can be associated with mild CP

 

Pathology

 

Juvenile Hallux Valgus

 

Congruent joint

- 50% compared with 9% in adult HV

 

Metatarsus primus varus

- increased IM angle

- often the primary deformity

 

Epiphyses usually still open

 

Oblique first TMTJ Angle

 

Ligamentous Laxity

 

Difference from Adult HV

 

Less severe

- no arthrosis

- sesamoid subluxation & pronation less common than in adult

- medial eminence not as prominent

- HVA not as big a contributor

 

Examination

 

Ligamentous laxity

 

T Achilles tightness

 

TMTJ hypermobility

 

Neurological examination

 

X-ray

 

Normal Angles

- HV < 15o

- IMA < 9o

- DMAA < 10o

 

Often DMAA increased

 

Management

 

Non-operative

 

Delay any surgery until

- adolescence

- physis closed (but not CI if open)

 

Well fitting shoes

 

Flexible flat foot may benefit from medial arch support

 

Operative 

 

Aims

- reduce DMAA

- reduce IMA

 

Congruent joint 

- less likely to progress (therefore treat conservatively)

- requires extra-articular realignment

 

Options

 

1.  Double or triple osteotomies

 

A.  Akin / proximal phalangeal osteotomy

- corrects interphalangeal angle

 

B.  Chevron biplanar distal metatarsal osteotomy

- adjust DMAA by adding closing wedge osteotomy

 

C.  Proximal metatarsal osteotomy

- further corrects IMA

 

2.  Hypermobile TMTJ common

- Lapidus procedure

 

Hallux Valgus Lapidus Procedure

 

3.  1st Cuneiform Opening Wedge Osteotomy

- severe IM angle with open 1st metatarsal epiphysis

- marked M-C joint obliquity with high IM angle

- opening wedge (iliac crest graft)

 

Complications

 

20% recurrence rate

- failure to correct IMA

 

Hallux varus 

- split extensor hallucis longus transfer

 

AVN 

- rare even in combined distal procedure

 

 

 

Onychomycosis

Definition 

 

Fungal infection of the nail

 

Epidemiology

 

Toenail affected 4x more common than fingernail

Prevalence has increased x 4 in last 2 decades

 

Aetiology

 

Dermatophytes most common cause

 

99% T rubrum & T mentagrophytes

- destroy nail by chemical or enzymatic process

 

Pathogenesis

 

First

- keratin of hyponychium is infected by the dermatophyte

 

Second

- involves nail bed & nail plate

- initially invades ventral plate which arises from nail bed

- intermediate plate has soft keratin & can become involved

- dorsal nail plate rarely involved

 

Clinical

 

Usually cosmetic problem only

- may become painful

 

Diagnosis

 

Microscopy of nail scrapings & culture studies

-> hyphae

- can culture if necessary

 

Management

 

Non-operative

 

Debride & remove part or all of nail

 

Topical agents less effective than systemic because don't target matrix

 

Oral antifungals 

- griseofulvin & ketoconazole (need up to 1 year of treatment)

- terbinafine (Lamasil) & itraconazole (Sporanox) 

- more effective with shorter treatment (3-6m)

- remain in the nail for 6 months

 

Operative

 

Zadek's

Terminal Syme amputation

 

Sesamoids

Anatomy

 

3 Sesamoids may be present in great toe

- 2 almost always present on plantar aspect of MTPJ

- 1 may be present on plantar aspect of IPJ

 

MTPJ sesamoids most important

- embedded in FHB tendons

- held together by intersesamoid ligament & plantar plate

- each side of crista / inter-sesamoid ridge

- articulate with plantar facets of 1st MT

 

Tibial usually larger than fibula

 

Tibial more impacted in weight bearing than fibula

- higher incidence traumatic injury to tibial

 

Insertions

- FHB

- Adductor hallucis

- Abductor hallucis

- Plantar plate

- Intersesamoid Ligament

- Plantar aponeurosis

 

Orientation

- Proximal to MT head in stance

- Pulled under MT head with DF / toe off

 

Ossification

- between 7-10 years

- often multiple centers 

- may result in bipartite / tripartite appearance

 

Bipartite

- fibular rare

- tibial bipartite in ~ 10% 

- bilateral in ~ 25% of these

- congenital absence - one or both

 

Bipartite Sesamoid

 

Blood Supply

 

Type A 50% medial plantar artery and plantar arch

Type B 25% plantar arch

Type C 25% medial plantar artery

 

Increased risk of AVN if only single vessel into sesamoid

- which is seen in Type C more commonly than B

 

Functions

- absorb weight bearing pressure

- reduce friction

- protect tendons

- act as fulcrum to inc mechanical force of FHB

- Sesamoids and Collats provide medial / lateral stability of 1st MTPJ

 

History

 

Do not always present with symptoms directly referable to sesamoids

- generalized pain around Hallux

- pain after sudden pop or snap after running

 

Pain as hallux extends in terminal part of stance phase

 

Neuralgic symptoms or numbness if digital nerve compressed 

 

Examination

 

Local tenderness

Decreased strength on PF

Pain on passive DF

Loss of active & passive DF

 

Cavus foot

- plantar flexed 1st ray 

- excess axial load on sesamoid

 

Imaging

 

Standard lateral not very useful

- AP, medial oblique, lat oblique, axial

 

Bone scan 

 

Projection important to differentiate sesamoids from MTPJ

- may be obscured by AP scan

- PA or oblique with Collimation useful for DDx

- caution with increased uptake in ~25% of asymptomatic patients

- marked difference to contralateral side significant

 

MRI 

 

Useful for Osteomyelitis

 

CT 

 

Useful for post-traumatic changes 

- compared with contralateral side

 

Conditions

 

1.  Fracture

 

Difficult to differentiate from symptomatic multipartite sesamoid

- especially if fracture through bipartite 

- comparison X-ray with contralateral foot 

- MRI & bone scan with pin hole collimation useful

 

 Fractured SesamoidSesamoid Fracture CT

 

Non operative management

- initial treatment

- orthosis / dancer's pad / cast / MT bar

- especially stress fracture

 

Surgery

- excision of most comminuted fragment or entire sesamoid

- preferred over bone graft in most cases

- consider graft for athletes

 

2.  Osteochondritis

 

Infrequent

- osteonecrosis with regeneration & calcification may be present

- may be enlarged / deformed / sclerotic with mottling / fragmentation

 

3.  Infection

 

Rare except diabetic neuropathy

- Pseudomonas relatively common 

 

4.  Sesamoiditis

 

Repetitive trauma especially teens / young adults

- Inflammation & bursal thickening may be present

 

5.  Osteoarthritis

 

May be in conjunction with MTPJ OA / RA / Gout

 

Management

 

Stiff soled or rocker bottom shoe + MT pad

 

Sesamoidectomy

- may decreases pain

- Don't remove both

- leads to clawing of hallux

 

6.  Intractable Plantar Keratoses

 

Usually caused by

- sesamoid with plantar located osseous prominence

- plantarflexed first metatarsus / cavus

 

Management

 

Intractable lesions

- sesamoid shaving or resection

- avoid shaving if 1st MT is plantarflexed

- consider basilar dorsiflexion osteotomy

 

7.  Nerve Impingement

 

Impingement of medial branch plantar digital nerve on medial sesamoid

 

Sesamoidectomy

 

Principles

 

1.  Never excise both 

- high incidence of Hallux Valgus or Cock Up deformity

2.  Never make incision directly over sesamoid

3.  Always repair adductor if excising lateral sesamoid

 

Produce mechanical defect in FHB unit

- can excise up to 2/3 of either without disturbing ligamentous attachments

- may relieve pain without disrupting FHB mechanism

 

Tibial 

 

Tibial sesamoid excision

- 3cm plantar medial incision

- Medial branch plantar digital nerve identified & retracted

- Locate sesamoid by palpation

- Flex hallux 20-30o & retract FHL

- Incise inter-sesamoid ligament & pull sesamoid medial

- Shell out from capsule & plantar plate with knife

- Imbricate capsule

 

Tibial sesamoid shaving

- Plantar medial approach

- Excise plantar 1/2 with microsagittal saw

- Smooth with rongeur

 

Fibular

 

Approach

- either dorsal or plantar approach

- dorsal demanding due to depth

- plantar - NV bundle & FHL to negotiate  

 

Dorsal incision 

- from 2-3 cm proximal to web space

- Identify & protect branch SPN

- Interval between Adductor Hallucis & joint capsule opened

- Tendon of Add Hallucis reflected from lateral sesamoid

- Grasp sesamoid & divide inter-sesamoid ligament

- Release proximal & distal & excise

- repair adductor

- Close skin 

 

Plantar incision

- Flex hallux

- 4cm incision between MT 1 & 2

- Retract NV bundle either lateral or medial

- Locate FHL & open pulley over it

- Flex hallux to relax FHL & retract medially

- Divide inter-sesamoid ligament

- Excise proximally & distally

- Reattach cuff of FHB

- Consider oblique wire across MTPJ

 

Complications

 

Cock up toe

Hallux valgus or varus

Nerve injury

Fat pad disruption

Painful plantar scar if plantar incision

Turf Toe

Definition

 

Hyper-dorsiflexion injury to 1st MTP joint

 

Management

 

Grade 1 - Mild sprain

 

Symptoms

- minimal swelling / ecchymosis

 

Management

- return to play immediately

- RICE / NSAIDS

 

Grade 2 Partial tear plantar plate

 

Symptoms

- tender / swelling / ecchymosis

 

Management

- return to sport 1-2 weeks

- taping toe to prevent hyper-extension

- stiff soled shoes

 

Grade 3 complete tear plantar plate

 

Symptoms

- marked pain / swelling / ecchymosis / marked decrease ROM

- +/- sesamoid fracture / disruption of FHB

 

Management

- return to sport 3-6 weeks

- surgical removal of loose bodies

 

Unstable

- see proximal displacement of sesamoids

- require operative repair of plantar plate

 

Lesser Toes

Bunionette

Definition

 

Painful prominence of lateral eminence of 5th metatarsal head 

 

Coughlin Classification 

 

Type I deformity 

- prominent lateral condyle 5th metatarsal head

- lateral condylectomy

 

Type II deformity 

- lateral bowing of 5th metatarsal

- chevron osteotomy

 

Bunionette Type 2

 

Type III deformity 

- increased 4-5 IMA > 10° (N ~5°) 

- straight but laterally deviated 5th metatarsal

- midshaft osteotomy / Scarf

 

Type IV 

- combination (especially RA)

 

Clinical Features

 

Often leads to overlying corns & calluses

- lateral keratosis / plantar keratosis / combined

 

Bunionette

 

X-ray

 

4-5th IMA is normally 5°

5th MTPJ angle is 10°

 

Management

 

Non-operative

 

Pressure relief by padding

Shoe stretching

Changing to wider softer shoes

Broad-toed shoes & insole

Callus paring

 

Operative

 

Procedure depends on the underlying deformity

- true proximal osteotomies avoided due to blood supply 

- remember problems with Jones fracture

 

1. Lateral Condylectomy

 

Indications

- Type I deformity

- enlarged lateral metatarsal head

- no increase in IMA

 

2. Coughlin Proximal Osteotomy

 

Indication

- type II deformity / lateral bowing of 5th metatarsal

 

Technique

- medial displacement

- midshaft oblique osteotomy

 

3. Chevron Osteotomy

 

Indication

- Type III lesion 

 

4. Metatarsal Head Resection

 

Issue

- can get transfer pain

 

 

 

 

Claw / Hammer / Mallet / Curly

Background

Deformities

 

Mallet

- DIP flexed

- MTP / PIPJ neutral

 

Hammer 

- PIP flexion

- DIPJ neutral / extended

 

Simple - MTP not involved

Complex - MTP hyper-extended

 

Claw 

- PIPJ and DIPJ flexed

- MTPJ hyperextended

 

Curly toe 

- PIP and DIP flexion

 

Great toe 

- only have hammer 

- no mallet

 

Claw toe v hammer toe 

 

1. Claw toes frequently are caused by neuromuscular diseases

- often a similar deformity is present in all toes

- in hammer toe deformity only one or two toes are involved

 

2. Claw toes always have extension deformity at the MTPJ

- in hammer toe deformity extension of metatarsophalangeal joint may or may not be present

 

3. Claw toes often have a flexion deformity at the distal interphalangeal joint

- this usually does not occur in hammer toes

 

Anatomy

 

EDL 

- divides 3 slips over P1

- middle - P2

- sides - P3

- thus no insertion to P1

- but main action is to extend P1 at MCPJ  

- only extends IPJ if P1 neutral or flexed

 

EDB

- arises upper and lateral surface of calcaneum

- has four tendons

- one inserts into base P1 great toe - EHB

- other 3 into lateral side of EDL tendon toes 2 - 4

 

FDL 

- inserts P3

- flexes DIP

 

FDB 

- inserts P2

- flexes PIP 

 

Interossei 

- dorsal to transverse ligament

- insert P1 (mostly) and extensor hood

- mainly MTPJ flexor

 

Lumbricals 

- plantar to transverse ligament

- insert extensor hood only

- mainly allow IPJ extension with MTPJ flexion

 

Aetiology

 

Shoe Wear

- main cause is ill-fitting shoes

 

Hallux valgus

 

Trauma

- compartment syndrome

- fracture

- tendon or ligament injury

 

Anatomic 

- long 2nd ray with buckling of toe

- irregularly shaped P2 with deviation of P3

- long 4th toe with curling under 3rd toe

 

Neuromuscular

- Polio

- CMT

- MD

 

Inflammatory arthritis

- RA

 

Congenital

- Syndactyly

- CMT

 

Insensate Foot

- DM

- Hansen's disease

 

Claw Toe

Definition

 

Hyperextension of MTPJ and PIPJ / DIPJ flexion

- usually all toes affected 

 

Claw Toes

 

DDx

 

1.  Complex hammer

- hammer toe with MTPJ extension

- hammer usually affects second toe

 

2.  Curly toe

- normal MTPJ

- flexed PIPJ and DIPJ

 

Associations

 

Cavus foot 

Compartment syndrome

Diabetic neuropathy

Rheumatoid arthritis

 

Pathology

 

Imbalance between intrinsics and extrinsics

- intrinsic weak (MCPJ flexion and IPJ extension)

- extrinsics strong

 

MTPJ  

- extension strong

- flexion weak

 

IPJ

- extension weak

- flexion strong

 

P1 subluxes dorsally

- it pushes the MT head plantar-ward 

- leading to metatarsalgia

 

Cavus foot 

- claw occurs not only due to intrinsic weakness but because of plantar flexed MT's 

- lead to dorsiflexion at MTPJ's 

- results in flexion of IPJ's as seen above

- If claw flexible may correct if reduce MT's

 

History

 

Pain & callosities under MT heads (metatarsalgia)

 

Examination

 

Hindfoot

- cavus

- coleman block

 

Forefoot

- characteristic deformity

 

Calluses

- dorsum PIPJ

- bleow MTPJ

 

Mobile or fixed of MTPJ / PIPJ crucial

 

Flexible

- claw disappears with ankle PF 

- returns with DF ankle (tight long flexors)

 

Cavus foot

- when DF to correct MT claw actually improves (tight plantar fascia) 

 

Management

 

Non-operative

 

Extra width and depth toe box shoe 

MT dome

 

Operative

 

Significant deformity of the hindfoot ± a cavus foot should be addressed first if symptomatic

 

Surgical Algorithm

 

1.  Flexible Deformity PIPJ / MCPJ

 

Girdlestone Taylor FETT 

- divide FDL in two and suture dorsally over P1

- +/- Extensor tenotomy & Dorsal MTPJ capsulotomy

 

2.  Fixed PIPJ Deformity / Flexible MCPJ

 

A.  Du Vries Excisional Arthroplasty PIPJ

- resection of head & neck of P1 

- stabilise with K wire

- aiming for fibrous union

- ROM 15o

 

B.  Extensor tenotomy + PIPJ Fusion

 

+/- Dorsal MTP capsulotomy MP joint

 

3.  Fixed PIPJ / MCPJ 

 

PIPJ arthrodesis + Extensor tendon tenotomy 

+ dorsal MTPJ capsulotomy

+ MT neck osteotomy

  

4.  Great toe involved

 

Jones procedure

- arthrodesis of IPJ

- EHL to MT neck 

 

Metatarsal options

 

Persistent MTPJ DF main cause of failure

 

Options

1. Excision of MT head (Keller's)(RA)

2. Distal metatarsal oblique osteotomy (Weil)

3. Hibbs (if from cavovarus)

 

Techniques

 

1.  FETT Technique / Modified Girdlestone Taylor

 

A.  Release FDL distally / divide into two

- 2 plantar incisions P2 and P3

- transverse incision plantar aspect P3

- divide FDL, protect NV bundles

- transverse incision plantar aspect P2

- harvest FDL and split in two

- can do single longitudinal plantar incision

 

B. Pass FDL over plantar aspect P1

- dorsal incision over P1

- place clamp each side of hood

- don't trap digital nerve

- bring tendon through incision slot in extensor tendon over P1 on each side 

- if over P2 will not work

- toe placed in approximately 20 degrees of plantar flexion at the MTP joint

- suture to each other & ED

- if varus or valgus take whole FDL either side

 

2.  PIPJ fusion 

 

Principles

- important to shorten the toe

 

Technique

- Ellipse of skin excised over dorsum PIPJ

- Extensor tendon taken in the ellipse

- release the collaterals so that P1 subluxes into operative field 

- elevate volar plate off P1

- bone cutters to resect P1 condyles

- resect base P2

- retrograde K wire out through P2 and P3 first

- back through P1, rest against subchondral bone

- bend wire over and tape

 

Risk

- check blood supply at end of case

- if problematic

- release dressings / warm / increase BP

- can use antispasmodic

- will usually reperfuse over 5 minutes

- keep patient asleep in meantime

- need to have ischaemia as part of consent

 

3.  Weil Osteotomy 

 

Technique

- Dorsal metatarsal exposed

- web space incisions if doing multiple toes

- homan retractors each side of MT

- saw enters at edge of articular surface dorsally

- Blade angled as low / horizontal as possible

- When osteotomy complete the MT head slides back

- Needs to slide back at least 5mm

- Then fix with screw from dorsal to distal plantar

- Amputate leading edge of proximal fragment

- if have valgus or varus deformity then can correct for this

 

Weil Ostetomy PIPJ FusionWeil Osteotomy PIPJ Fusion Lateral

 

 

Curly Toe

Definition

 

Under-riding toe

- toe lies beneath adjacent toe

- congenital deformity

 

Pathology

 

Due to tight FDL & FDB

- capsule initially normal

- becomes constricted with time

 

Clinical

 

Usually 3rd toe

- flexed, ER, medially deviated

 

Deformity accentuated when standing

 

Ankle dorsiflexion

- increases deformity

 

May present with

- cosmetic concerns

- callus & blister formation

 

Management

 

Non-operative

 

Most don't require treatment

- most non symptomatic

- 25% improve spontaneously

 

Operative

 

If symptoms judged sufficient

- wait till > 4 years old

 

Options

 

Flexible deformity 4 - 12 year old

- flexor tenotomy thru plantar skin

- just divide FDL

 

Fixed deformity > 12 years old

- resection / arthrodesis of IPJ

 

Case scenario

- 2 year old with curly toes

- nil other abnormality

- vast majority will improve

- give stretches for parents to do

- only if continual problem, do FDL release

 

 

Hammer Toe

Definition 

 

Flexion deformity PIPJ with

- MTPJ normal / simple

- MTPJ hyper-extended / complex

- DIPJ any position

- P1 may become subluxed or dislocated

 

Aetiology

 

Uncertain

 

Long second toe / MT

Hallux valgus

Tight shoes

 

Examination

 

Hammer Toe Clinical Photo

 

Calluses

- dorsum of PIPJ

- beneath second MT head

 

Rigid v flexible

Correctable / Non correctable

 

Management

 

Non-operative

 

Extra depth or padded shoe, low heel

 

Operative

 

Concepts

- need to ensure enough room for corrected toe / shorten toe

- may need to treat HV as well

- may need to release flexor tendons if tight

 

1.  Flexible Deformity

 

Girdlestone-Taylor FETT

 

2.  Fixed PIPJ

 

A. DuVries Arthroplasty

 

B. Extensor tendon tenotomy + PIPJ fusion

 

C. Partial Proximal Phalangectomy

- leaves toe floppy

- poor cosmesis

- only as salvage

 

3.  Fixed PIPJ and Subluxed MTPJ

 

Extensor Tendon Tenotomy + PIPJ fusion

+ Dorsal MTPJ capsulotomy

+ MT osteotomy

 

PIPJ Fusion Weil OsteotomyPIPJ Fusion Weil Osteotomy Lateral

 

 

 

Mallet Toe

Definition

 

Flexion deformity of DIPJ 

 

Aetiology

 

Usually in 2nd toe

- Long second MT

- Constrictive footwear

 

Clinical

 

Pain over

- tip of toe

- over dorsum of DIP joint

 

May be corn on tip of toe 

 

Fixed or flexible

 

Management

 

Non-operative

 

Shoes with roomy toe box

 

Operative

 

Surgical Algorithm

 

1.  Flexible

 

Percutaneous FDL tenotomy

 

2.  Fixed

 

A.  Excision arthroplasty of DIPJ  ± FDL release

 

B.  Arthrodesis 

 

C.  Terminal Symes amputation

 

3.  2nd MTPJ Dislocation

 

Reducible dislocation 

- Hammer toe repair

 

Reducible but unstable 

- FETTS + Hammer toe repair

 

Irreducible 

- E/O MT head + FETT + Hammer toe repair

 

 

Fifth Toe

Over-riding Fifth Toe

 

Deformity

 

5th toe adducted & overrides 4th toe

- extended, adducted & laterally rotated at MTPJ

 

Pathology

 

Toe arises more dorsally than it should

 

Contracture of EDL tendon

Contracted dorsal skin & dorsal MTPJ capsule

 

Aetiology

 

Usually congenital deformity

- toe usually hypoplastic

 

Clinical Features

 

Cosmetic deformity

Problems with footwear

Usually bilateral

Usually needs surgery (compared with underriding or curly)

 

Non-operative Management

 

Strapping & taping ineffective

Broad toe box

 

Operative Management

 

Mild / Moderate - Butler procedure 

- racquet shaped incision dorsally

- dorsal limb over extensor tendon

- circumferential limb must preserve NV bundle

- EDL and dorsal capsule divided

- toe swung back into position and sutured

 

Severe - Lapidus procedure 

- EDL transfer to AbDM

- curvilinear incision

- cut EDL over mid MT proximally leaving attached distally

- capsule release MTPJ

- tendon transferred medial, plantar and laterally around P1

- sutured to abductor digit minimi

 

Underriding fifth toe

 

Opposite deformity of above

 

Thompson excisional arthroplasty

- Z incision laterally over P1

- proximal phalanx resection and capsule imbrication

- K wire

 

Cock Up Deformity 

 

Deformity

- of MTP 

- realign at MTPJ & IPJ

- usually hammer toe deformity as well

 

Surgical Algorithm

 

Mild to moderate 

- extensor tenotomy & fixed hammer toe repair

 

Severe 

- Ruiz-Mora procedure

- resection arthroplasty of proximal phalanx

- elliptical plantar incision with proximal phalyngectomy

 

Salvage

- end up with floppy toe 

- syndactylisation may be salvage

- but swapping one deformity for another

 

 

 

Keratotic Deformities

Definitions

 

Corn

- accumulation of keratotic layers of epidermis

- thickened epithelium elevates prominence causing further pressure

 

Hard Corn

 

Due to extrinsic pressure from footwear

- most common on lateral aspect of 5th toe

- over head of proximal phalanx

 

Soft Corns

- on the condyle of proximal phalanx between the toes

- due to pressure between adjacent bony prominences

- DDx fungal infection

- soft due to moisture

- commonest is medial aspect 5th toe

- also common at base of web space overlying 4th proximal phalanx lateral condyle

 

Aetiology

 

Combination of Extrinsic or Intrinsic pressure

 

Extrinsic 

- shoewear increasing compression 

 

Intrinsic 

- underlying prominent condyle of P1

 

X-ray 

 

See on plain film with marker over corn

 

Non-operative Management

 

Usually not successful long term

- education re shoewear / wide shoe with extra depth toebox

- lambs wool dressing or foam pads

- trim hyperkeratosis

 

Operative Management

 

Isolated small keratosis over 5th PIPJ

- treat with condylar resection of 5th PIPJ alone

 

Keratosis over 5th PIPJ & base 4th web

- treat with resection of 5th condyle & lateral proximal phalangeal condyle of 4th toe

 

Intractable Plantar Keratoses

 

1.  Resection Arthroplasty of Mann and DuVries 1973

 

Results

- 85-90% patient satisfaction

 

Technique

- dorsal Incision over MTP

- retract EDL

- divide transverse MT ligament

- severe collaterals and deliver head

- remove 2-3mm of distal MT head

- remove the plantar lip so approximately 50% of head has been excised

 

2.  Giannestra Shortening Oblique MT Osteotomy

 

Best when long MT

- aim to shorten 5-6mm

- fix with screw

 

3.  Dorsal Closing Wedge Osteotomy

 

Aim for dorsal wedge of 2-3mm

- fix with cross K-wires

- must pop for 6/52

 

 

 

 

 

Lis Franc

History

Jacques LisFranc De St-Martin (1790 - 1847)

General Surgeon in Napoleonic army

 

Mechanism

 

High energy

 

1.  Twisting / Abduction injury of forefoot

- original description is fall from horse with foot caught in stirrups

- MVA

 

2.  Axial Loading

 

A Extrinsic axial compression applied to heel

B Extreme ankle equinus with axial loading of body weight

 

3.  Direct Crushing

- to dorsum of mid-foot

- greatest risk of compartment syndromes and open fractures

 

Classification

 

A: Quenu & Kuss; Modified by Hardcastle (JBJS 1982)

 

1. Homolateral 

- all 5 metatarsals displaced in same direction

- most common

 

Homolateral Lis FrancLis Franc Homolateral

 

2.  Isolated 

- only 1st MT injured / displaced

 

3.  Divergent 

- 1st MT displaces medially

- other 4 MT displace laterally

- least common

 

B: Myerson

https://www.ncbi.nlm.nih.gov/pubmed/3710321

A: Total incongruity (medial or lateral)

B: Partial incongruity

  B1: Medial

  B2: Lateral (most common)

C: Divergent displacement

  C1: Partial

  C2: Total

 

Anatomy 

 

Bony Stability

 

1-3 MT articulate with cuneiforms

4 & 5 articulate with cuboid

 

Bases of MT wider dorsally than plantar

- form 1/2 of Roman arch 

 

Metatarsal Base Roman ArchFoot CT

 

2nd MT is keystone of transverse MT arch

- medial cuneiform is recessed proximally

- mortise provided for base of second

 

Ligamentous stability

 

Lis Franc ligament

- plantar structure

- 1 cm long x 0.5 cm diameter

- base 2nd MT to medial cuneiform

- avulsion as 'fleck fracture'

 

Note: no intermetatarsal ligament from 1st MT to 2nd

 

Mobility (Sagittal)

 

Medial Column (1st MT) - 3.5 mm

Middle Column (2/ 3) - .6mm

Lateral Column (4/5) - 13mm

 

Examination

 

Swelling and pain

- out of proportion

- must suspect Lis Franc

 

Brusing plantar aspect foot

- indicative of Lis Franc Ligament rupture

 

Signs compartment syndrome

 

X-ray

 

Fleck sign

- avulsion of LF from base of 2nd MT

- can be only sign of isolated Lis Franc Injury

 

Lis Franc Fleck SignLis Franc Fleck Sign

 

Diastasis between 1st & 2nd MT

- may need to perform bilateral weight bearing stress view

 

Lis Franc Diastasis

 

AP / Assess medial column

- medial border 1st MT should line up medial border medial cuneiform

- medial border of 2nd MT should line up with medial border middle cuneiform

 

 Lis Franc Medial Column ViewFoot Medial Column Normal

 

Internal Oblique 30o / Assess lateral column

- medial border 3rd MT line up with medial border lateral cuneiform

- medial border of 4th MT line up with medial border cuboid

 

Lis Franc Lateral ColumnLis Franc Lateral Column Disruption

 

CT scan

 

Confirm displacement of MT from respective joints

 

Lis Franc Displaced TMT Joints CT0001Lis Franc Displaced TMT Joints CT0002

 

Identify fleck sign

 

Lis Franc CT Fleck SignLis Franc CT Fleck Sign and Diastasis

 

Identify dorsal displacement of metatarsals

 

Lis Franc CT Dorsal Displacement MTLis Franc Dorsal Displacement

 

Compression fractures / nutcracker of cuboid

 

Cuboid Fracture Lis Franc

 

MRI

 

Confirm oedema or tear of Lis Franc ligament

Bone brusining tarsometatarsal ligaments

Subluxation of ligaments

 

Intraoperative

Curtis stress views

Hindfoot stabilised & forefoot pronated/ abducted

 

Prognosis

 

Residual pain & stiffness with non-anatomical reduction

- 2° OA

- progressive planovalgus

 

Management

 

Non Operative

 

Sprains with no displacement

- 6/52 in NWB SLPOP

- close serial follow up

- strapping/ medial arch support 6/12

 

Operative

 

Indications

 

Any displacement

 

Closed Technique

 

Indication

- isolated Lis Franc with diastasis

- early diagnosis and treatment

 

Technique

- longitudinal traction

- reduction first intermetatarsal joint

- percutaneous fixation screws

- from medial cuneiform to 2nd metatarsal

 

Lis Franc Isolated Injury FixationLis Franc Medial Column ORIF

 

Open Technique

 

Timing

- wait for swelling to reduce

- may take 2 - 3 weeks

 

Goal

- reduced and stabilise all MTJ that are injured

 

First incision

- dorsal

- between 1st and 2nd MT

- lateral to EHL

- protect branches of SPN

- dorsalis pedis and DPN are in this intermetatarsal space

- very difficult to identify

 

Reduction

- clean out joint

- reduce first and second metatarsal to cuneiforms

- check AP reduction

 

Provisional fixation

- K wire 1st MT to medial cuneiform

- K wire 2nd MT to intermediate cuneiform

- K wire medial cuneiform to base 2nd MT

- +/- K wire medial to intermediate cuneiform if unstable

- insert 4.0 mm cannulated screws

 

Lis Franc Post ORIF

 

2nd incision between 3rd and 4th MT if required

- reduce 3rd and 4th MTPJ

- K wire / screw 3rd MT to lateral cuneiform

- Fix 4th and 5th to cuboid with K wires

- 5th K wire usually inserted percutaneously

- check with oblique view

- may use screw / k wire to 3rd MTPJ

 

Post op

 

Strict NWB for 8/52

- Lis Franc ligament takes time to heal

 

Removal of K wires at six weeks

 

Screw removal

- no sooner than 4/12

- broken screws rarely bothersome

 

Complications

 

Compartment Syndrome

 

Open fracture

- closed reduction and hold with external fixator

 

Midfoot Arthritis

- can develop later

- require midfoot fusion

- some surgeons advocate primary fusion if joint surfaces very damaged / comminuted

Metatarsalgia

DDx Metatarsalgia

Definition

 

Pain in the forefoot in the region of the MT heads

 

3 groups

 

1.  Localised

 

Morton's neuroma

Freiberg's

Stress fracture

Infection / tumour

Plantar Keratosis

Plantar Wart

 

2.  Systemic disease

 

RA

 

3.  Altered forefoot biomechanics / Transfer Metatarsalgia

- irregular Distribution of MT load

 

A  1st ray insufficiency syndrome

- splayed forefoot

- 1st ray unloaded

 

Metatarsalgia Splayed Foot

 

B.  Short 1st MT 

- > 2 cm back from 2nd MT

- varus 1st MT

- 1st ray unloaded

 

Metatarsalgia Short 1st Metatarsal

 

C.  Hyper-extended MTPJ with claw toe

 

D.  Iatrogenic

- bunion surgery

- excision of metatarsal head

 

E.  Lax soft tissues

- Lis franc injury

 

F.  Flatfoot

- supination, elevation of 1st metatarsal

 

Freiberg's

Definition

 

Crushing osteochondritis of metatarsal head

 

Frieberg's

 

Epidemiology

 

Usually 2nd metatarsal (80%)

- occasionally third

- can occur in any

 

Age 10-15 years

- peak 15 year old girls

- F:M = 3:1

- occurs during the growth spurt at puberty

 

Bilateral in 6%

 

Aetiology

 

Trauma / repetitive stress

- interrupts blood supply to epiphysis

- fragmentation and AVN

 

2nd MT prone to stress fracture & AVN

- long MT

- fixed base

- thin shaft

 

Pathology

 

Ischaemic necrosis of epiphysis

 

Commonly have synovitis as well

 

Clinical

 

Tender enlarged MT head

- pain on dorsiflexion

- limited dorsiflexion due to synovitis or degenerative change

 

DDx

 

MTPJ synovitis / arthritis / synovial cyst

Interdigital neuroma

Stress fracture

 

X-ray

 

Enlarged flattened MT head

- widened joint space

- osteolysis & collapse in late stages

 

Leads to MTPJ OA

 

Classification Smillie 

 

Stage I 

 

Subchondral fissure in epiphysis

 

Xray normal

Bone scan / MRI positive

 

Stage II 

 

Collapse of dorsal central portion of MT head

 

Xray

- slight widening of joint space

- sclerosis of epiphysis

 

Stage III 

 

Friebergs Stage III

 

Xray

- progressive flattening of the head / osteolysis / collapse

 

Stage IV 

 

Xray

- fragmentation of epiphysis

- multiple loose bodies

 

Stage V 

 

Friebergs Stage V

 

Xray

- advanced degenerative arthrosis

- joint space narrowing

- hypertrophy of MT head

- osteophyte formation 

 

MRI

 

 

Management

 

Non-operative

 

Algorithm

 

Limit activities 6/52

Metatarsal bar / preMT dome to unload MT head

Avoid high heels

Consider POP / moonboot to reduce symptoms

 

Operative 

 

Options

 

Synovectomy & joint debridement / removal of loose bodies

 

Indication

- stage II / III disease

 

Osteophyte removal / Cheilectomy

 

Closing wedge extension osteotomy

 

Concept

- dorsiflexion osteotomy

- most affected portion MT head is dorsal

- redirects plantar articular surface

 

Excision of MT head 

 

Indication

- severe disease

 

Issue

- not a great operation 

- associated with hallux valgus and transfer metatarsalgia

 

Morton's Neuroma

Definition

 

Benign enlargement of the common digital branch

- usually 3rd webspace

 

Mortons Neuroma Common Site

 

Anatomy

 

Found at level of or just distal to MT heads

- deep to the deep transverse MT ligament

 

Epidemiology

 

Classically women between 40 and 60

 

Aetiology

 

Can be traumatic but usually degenerative

 

Pathology

 

Demyelination of nerve fibres with fibrosis

 

History

 

Pain with weight bearing

- worse with wearing tight shoes

- in the ball of foot

- may be shooting type pain

 

Numbness / tingling in the affected toes

 

Examination

 

Mulder sign

- palpate webspace with fingers superiorly and inferiorly

- with other hand compress metatarsal heads together

- either palpate the lump or feel a click

 

Mulders Sign

 

Xray

 

Usually normal

- can have splaying of MT heads

 

US / MRI

 

Aid in confirming the diagnosis

 

Management

 

Non operative

 

Wide toe box

Metatarsal Pads

HCLA - Temporary relief

Sclerosing injections / phenol

- can solve problem

 

Operative

 

Options

- resection (dorsal or plantar)

- decompression

 

Resection Technique

 

Dorsal incision

- beginning at webspace edge

- separate MT with lamina spreader / retractor

- divide deep MT ligament / can preserve especially in athletes

- identify common digital nerve proximally

- identify neuroma / place forceps under

- resect proximal to neuroma

- resect distal to bifurcation

- send to pathology to confirm

 

Mortons Neuroma IncisionMortons Neuroma 1Mortons Neuroma 2

 

Mortons NeuromaMortons Neuroma

 

Complications

 

Patient will have numbness

Painful stump neuroma (revise via plantar approach)

Hammer toe (inadvertant lumbrical resection)

Pain secondary to instability / division intermetatarsal ligament

Plantar Warts

Pathology

 

Human papilloma virus

 

Occur in any part of sole

 

Clinical Features

 

Do not project above level of skin

- because of pressure of weight bearing

- seldom more than 1cm in diameter

- skin surrounding wart thickened and raised

- edge clearly demarcated from surrounding skin

 

Severe localised pain on walking

 

Local tenderness on pressure

 

DDx

 

Plantar callosities

- warts occur anywhere

- callosities occur over points of pressure

- warts have clearly defined edge with possible cleft between it and skin

- callosities blend with surrounding skin

- warts have punctate bleeding

 

Treatment

 

Non-operative

 

Cauterisation / freezing / Paring

 

Operative

 

Curettage and cauterisation of base

- (care taken with digital nerves etc)

 

Miscellaneous

Accessory Medial Cuneiform

Accessory Medial Cuneiform0001Accessory Medial Cuneiform0002Accessory Medial Cuneiform0003

 

Accessory Navicular

Incidence

 

1 - 2 %

 

Anatomy

 

Medial Aspect of foot

- proximal to navicular

- part of T posterior tendon

 

Usually will fuse with navicular (50%)

 

Issues

 

1.  Probably not a cause of flat foot

- excising accessory navicular / rerouting / reattaching tibialis posterior

- will not help pes planus

 

2.  Pain

- may fracture

- may cause insertional tendonitis

 

Classification

 

Type 1

 

Small ossicle proximal to insertion

 

Type 2

 

Synchondrosis

- may fracture with injury

 

Accessory Navicular Fractured SynchondrosisAccessory Navicular

 

Management

- treat in cast 6/52

- excise if symptomatic

 

Type 3

 

Large cornuate navicular

- likely that the accessory has fused

 

Accessory Navicular Cornuate

 

Bone Scan

 

Acessory Navicular Bone Scan

 

Identifies if accessory navicular cause of symptoms

 

MRI

 

Show oedema about a symptomatic accessory navicular

 

DDx

 

T Posterior tendonitis

Navicular stress fracture

 

Management

 

Non operative

 

Rest

Moon Boot

 

Operative

 

Kidner Procedure

- medial incision dorsally over navicular

- enucleate accessory navicular from tendon

- may need to take away navicular prominence

- reattach tendon if necessary through drill holes

 

Brailsford Disease

Definition

 

Adult form

- 45 year old females

- more severe than Kohler's

 

Symptoms

 

Intense pain +/- oedema & inflammation

- often pronounced limp

- marked flat foot with prominant navicular

 

Radiology

 

Navicular narrowed

- lateral part dense, sclerotic & thin

- occasional fracture line

- degenerative TNJ

- due to wedge shape concentrating forces dorsally

- fracture collapses

 

Surgery

 

Often necessary

- to graft navicular & restore anatomy

Gait

Gait cycle

 

Definition

- from point of initial contact of one foot with the ground

- until that foot hits the ground again

 

Two parts

 

1.  Swing phase

- foot not in contact with ground

- 40% walking gait

 

2.  Stance phase

- heel strike to toe off

- 60% of walking gait

- 3 rocker phases

 

Rocker Phases

 

1st rocker phase / Heel Strike

 

Ankle plantar flexes 

The foot is lowered onto the ground under the control of the eccentrically acting tibialis anterior

Foot pronates with flattening of medial arch, and hind foot in valgus to allow show absorption

 

Lose with

- heel pain

- fixed equinus

- true or apparent LLD

 

2nd rocker phase / Stance Phase

 

Progressive  dorsiflexion of the ankle allows the tibia and the centre of gravity to progress over the foot

- modulated by the eccentrically acting triceps surae

- maximal pronation

 

3rd rocker phase / Toe Off

 

The foot rotates over the MT heads

Foot moves into supination, heel into varus

Tibialis posterior locks Midfoot so foot can act as a rigid lever

Concentric contraction of the triceps surae and FHL provides pushoff 

 

Loss

- painful forefoot (Hallux valgus / rigidus)

- loss of PF (NM, stiff hindfoot, ruptured TA)

 

Running

 

Walking ground reaction force 1.5 X body weight

Running ground reaction force 3 X body weight

 

Running has floating phase

- neither foot touching ground

 

Heel Pain DDx

Children

- Sever's disease

- Tarsal Coalition

- JRA

 

Adults

 

Trauma

- calcaneal fracture

- stress fracture

- lateral talar process fracture

 

Infection

- soft tissue

- calcaneal osteomyelitis

 

Tumours

- osteoid Osteoma

- osteochondroma

- bone Cyst

- ewing's Tumour

- metastasis

 

Inflammatory

- plantar fasciitis

- tibialis posterior tendonitis

- peroneal tendonitis

- achilles tendonitis

- retrocalcaneal bursitis

- fat pad atrophy

- tarsal tunnel syndrome

- RA / seronegative arthropathy

 

 

Sinus Tarsi Syndrome

Anatomy

 

Osseous canal between talus and calcaneum

- interosseous talo-calcaneal ligament

- cervical ligament

- joint capsule

- nerve endings / arterial anastomoses

 

Sinus Tarsi

 

Aetiology

 

Flat foot / overpronation

Inversion / sprain

 

Pathology

 

Hypothesis

- compression / pinching injury

- develop scarring of ligament and capsule

- predisposes to further pinching

 

Symptoms

 

Pain at lateral aspect ankle

- below lateral malleolus

 

May get pain when running on outside of foot / track work

 

Pain on uneven ground

 

Examination

 

Tenderness sinus tarsi

- soft indentation below and anterior to LM

 

Pain with eversion / inversion STJ

 

HCLA

 

Diagnostic

- relieves pain

 

MRI

 

Display fluid in sinus tarsi

May detect excess scar tissue

 

Management

 

Non operative Management

 

Usually very effective

 

Options

 

Rest

NSAIDS

Subtalar joint manipulation

Correction of over pronation / orthotics

HCLA

Orthotics to stabilise STJ

 

Operative

 

Lee et al Arthroscopy 2008

- 33 cases of subtalar arthroscopic debridement

- 88% good or excellent

- 12% fair

 

Findings

- partial tear interosseous ligament 88%

- synovitis in 55%

- partial tear cervical ligament 33%

- arthrofibrosis 24%

- soft tissue impingement 21%

 

 

Tarsal Tunnel Syndrome

Definition

 

Entrapment neuropathy of posterior tibial nerve within the tibial tunnel

 

Anatomy

 

Taral Tunnel

 

Flexor Retinaculum 

- medial malleolus to posterior calcaneum

 

Tarsal tunnel

- roof is flexor retinaculum

- tibia anteriorly

- talus and calcaneum laterally

 

Contents

- T. Post

- FDL

- Posterior tibial artery, tibial nerve

- FHL

 

Tibial nerve

- 3 terminal branches

- medial and lateral plantar

- medial calcaneal

- usually divide within tunnel

 

Aetiology

 

Specific cause identified in 60% cases

 

Idiopathic 

- 40% cases

- most common

 

Post-traumatic

- scarring after sprain

- bony prominence 2° calcaneal fracture

 

Inflammatory 

- RA

- tenosynovitis

 

SOL

- tumours

- ganglion of tendon sheath

- lipoma

- neurilemmoma (Schwannoma) 
- varicose veins

- medial talo-calcaneal bar

 

Accessory muscles

- FDL

 

History

 

Diffuse pain plantar aspect

- burning, tingling or numbness

- 1/3 have proximal radiation to leg

 

Aggravated by activity

 

Examination

 

Tenderness over Tarsal Tunnel

 

Positive Tinel's sign    

 

Palpate for thickening or swelling (cyst, ganglion etc)

 

Usually no sensory loss or weakness 

 

May see wasting of abductor hallucis

 

NCS 

 

At best 90% accurate

- Prolonged sensory conduction time in 75%

- Prolonged motor latency in 50%

- conduction velocity of CPN done to exclude peripheral neuropathy

 

MRI

 

MRI positive in 85% 

- FHL synovitis, dilated veins, mass, fracture, scar, etc

- 25% have contralateral MR findings with no symptoms

 

Diagnosis

 

At least 2 of

- Hx of tingling & burning

- positive tinels

- positive NCS

 

DDx

 

Local

- plantar fasciitis

- fracture

- tenosynovitis

 

Neurological

- peripheral neuritis

- diabetic neuropathy

- leprosy

- neurilemmoma

- neuroma

- spinal compression

 

Management

 

Non-operative

 

Of little benefit

- try NSAIDs

 

Operative

 

Surgical release by division of Flexor Retinaculum

 

Incision 

- 10 cm proximal to medial malleolus

- curved distally to TNJ

 

Release

- flexor retinaculum

- proximal investing fascia

- individual tendon sheaths / tibialis posteror in separate sheath

- abductor hallucis fascia

 

Follow and release both plantar nerves

- protect medial calcaneal branch

- runs off lateral plantar

 

Post op

- NWB for 3/52

 

Results

 

75% success if no underlying causes

Pantalar Fusion

Pantalar Fusion APPantalar Fusion Lateral

 

Indications

 

RA

AKJ and STJ arthritis

Trauma

Deformity

Talar AVN

 

Technique

 

Incision

- curved incision

- posterior border fibular

- curved anteriorly along peroneal tendons

- towards 4th MT

 

Exposure AKJ

- excise distal fibular

 

Exposure subtalar joint

- elevate peroneals and EDB

- divide TC interosseous ligament

 

Prepare arthrodesis

- decorticate / remove cartilaginous surfaces

- drill holes

- correct deformity

- AKJ 5o valgus, plantigrade, ER 10o

- STJ 5o valgus

 

Pantalar Fusion Talus AVN APPantalar Fusion Talus AVN Lateral

 

Fusion with IM nail

- insertion point

- in line with 2nd MT

- junction of posterior 2/3 and anterior 1/3 heel

- should pass through anterior aspect posterior subtalar joint

- insert nail

- distal locking screws calcaneum

- insert bone graft

- compress

- proximal locking

 

 

Peroneal Tendons

Dislocation

Definition

 

Anterior displacement of peroneal tendons out of peroneal groove

 

Epidemiology

 

Most common in young adults

 

Acute injury often missed 

 

Aetiology

 

Congenital

 

3 % neonates

- resolves spontaneously

 

Traumatic  

 

Occurs following sporting activities

- snow skiing

- football

- gymnastics

 

Forced DF and inversion

 

Anatomy

 

Fibro-osseous tunnel

- retro-malleolar groove

- lined by fibrocartilage

 

Anterior

- fibula 

 

Medial

- PTFL

- CFL

- PITFL

 

Peroneus longus

- posterolateral to PB

 

Superior Peroneal Retinaculum

- 2 bands

- fibula to lateral T Achilles

- fibula to posterolateral calcaneum

 

Inferior peroneal retinaculum

- lateral wall calcaneum below sinus tarsi

- no role in stability

 

Pathogenesis

 

1.  Traumatic

 

Violent contraction of Peroneal muscles 

 

Forced dorsiflexion and inversion

- injury to superior peroneal retinaculum

 

May be predisposition

- laxity of retinaculum

- shallow groove

 

Patient may also have tears

 

2.  Subluxation within sheath

 

Raikin JBJS Am 2009

- described intrasheath subluxation

- superior retinaculum intact

- patients still having painful snapping

- demonstrated by US

- half had peroneal tendons switching positions

- these patients had a convex groove

- these where treated with groove deepening and retinaculum reefing

- other half had a tear in PB through which PL could sublux

 

History

 

Acute

- sudden pain behind lateral malleolus

- snap may be heard

- unable to continue with activities

 

Chronic

- painful snapping of lateral ankle with activity

 

Examination

 

Tenderness & swelling behind LM

- pain or dislocation reproduced by active eversion & DF

 

Peroneal Tendon Dislocation 1Peroneal Dislocation 2

 

X-ray

 

Usually normal

 

May be avulsed fragment of cortical bone lateral to LM

- fleck sign

 

CT

 

Defines anatomy & relationships of tendons

- may detect anatomical variants

 

US

 

Very good at demonstrating subluxation

 

MRI

 

Detects tendinous & ligamentous injuries

 

Management

 

Opinion divided regarding acute injuries

- non-operative management v surgical repair

 

Most treat chronic injuries surgically

 

Non-operative

 

Acute injuries

- cast in plantarflexion for 6/52

 

Operative 

 

Indications

- acute injury in athletes

- chronic injuries

 

Acute Repair

 

Options

 

1.  Superior retinaculum stripped

- reattach to fibula via trans-osseous sutures / anchors

 

2.  Retinaculum torn

- primary repair

 

3.  Bony avulsion

- fragment reattached with sutures, wires or screws

 

Chronic

 

1.  Groove Deepening

- if necessary

- elevate cortical flap / decancellation / cortical recession

 

2.  Address tears in tendons

 

3.  Address superior peroneal retinaculum

 

A.  Direct repair / Advancement of superior peroneal retinaculum if able

 

B.  Reconstruction of SPR if attenuated

- periosteal flap from fibula

- slip of T Achilles left attached distally

- free plantaris / palmaris graft

 

C.  Rerouting under CFL

- substitution of CFL for peroneal retinaculum

- tendons transposed into inframalleolar tunnel

- division & repair CFL or fibular bone block with CFL

 

4.  +/- lateral ligament repair if needed

 

Surgical Technique

 

Findings

- chronic subluxation / anterior dislocation

- normal groove

- retinaculum stretched and not attached to normal insertion anterior fibula

- repair and tightened with suture anchors

 

Anterior Peroneal DislocationAnterior Peroneal DislocationAnterior stripping of SPR

 

Normal GrooveNormal GrooveSuture Anchors

 

Sutures PassedSutures Passed 2Repair 1

 

 

Tendonitis / Tendonopathy

Anatomy

 

Lateral compartment of leg

- run through retromalleolar groove

- pass superior and inferior to peroneal tubercle

- covered by inferior peroneal retinaculum

 

Peroneus longus

- origin lateral condyle of tibia and head fibula

- tendon PL superficial and inferior to brevis in retromalleolar groove

- runs in cuboid groove 

- insert plantar surface base of 1st MT and lateral aspect medial cuneiform

- everts the foot / plantar flexes the first ray / plantar flexes the ankle

- stabilises the medial arch in stance

 

Os peroneum

- sesamoid in PL

- level CCJ / articulates with cuboid

- 20% population

 

Os Peronei

 

Peroneus brevis

- origin middle third fibula and intermuscular septum

- inserts tuberosity base 5th

- abducts and everts the foot / plantar flexes the ankle

 

Nerve supply

- SPN

 

Definitions

 

Tendonitis

- inflammation of tenosynovium

 

Tendonosis

- degenerative change in tendon

-  can lead to tears

 

Aetiology

 

Tendonitis

 

Prolonged or repetitive activity

- usually after period activity

- runners and ballets dancers

 

Cavovarus hind foot

 

Tears

- acute injury

- chronic tendonitis

- dislocation / subluxation

 

Associations

 

Chronic lateral ankle instability

Peroneal tendon subluxation

Cavovarus hindfoot

 

Peroneal Tendon Tears

 

Incidence

 

P. brevis torn more frequently than longus

 

Classification

 

Sobel & Mizel 1993

 

Zone 1 

- behind lateral malleolus

- brevis more commonly injured 

 

Zone 2 

- distal to tip of fibula 

- longus only 

- cuboid tunnel acts as a fulcrum

- can get inflammation & swelling

- loss of excursion as brevis & longus skirt around pulley

 

History

 

Acute or chronic lateral ankle pain

 

Examination

 

Tenderness / swelling along tendons

 

Peroneal Tendon Swelling

 

Pain

- passive inversion and PF

- active eversion

 

DDx

 

Lateral instability

Fracture fibula / 5th MT / cuboid / Calcaneal

OCD talus

Loose body ankle

OA ankle

Sinus tarsi syndrome

Tarsal coalition

 

MRI

 

10 tendons about ankle

- axial views most usefull

- T1 displays anatomy

- T2 STIR shows tears 

- beware magic angle (fibres orientated 55 degrees to scan)

 

Findings

- tendon thickening / tendonopathy

- fluid about tendons / tendonitis

- tears

 

Peroneal TendonitisPeroneal Tendonitis MRIPeroneal Tendonitis MRI 2

 

Management

 

Non Operative

 

NSAIDS

Modification activities

Lateral heel wedge if hindfoot varus

Moon boot / SL walking cast

 

Operative

 

1.  Tenosynovitis

 

Open debridement and tenosynovectomy

- incision posterior to fibula and to base 5th MT

- sural nerve halfway between peroneals and T Achilles

- open peroneal tendon sheath

- debride synovitis

 

Peroneals Intra-operatively

 

Must also treat any

- inflamed os peroneum

- varus heel

- tears

 

2.  Tears

 

A.  <50% 

- excise &  repair tears by tubularisation

- incision 1 cm posterior to fibular

- from 5 cm above to base of 5th metatarsal

- immobilise with foot PF and everted to rest in POP

- after 2 weeks in moonboot for progressive mobilisation

 

B.  > 50%

 

One tendon torn

- tenodesis to other tendon

 

Both tendons torn

1.  2 stage reconstruction

 

2.  Tendon transfer FDL to PB / plantaris to PL

 

Pes Cavus

Calcaneo Cavus

Definition

 

Pure Cavus Deformity characterised by 

- dorsiflexion of Calcaneus 

- plantarflexion of Forefoot

 

Aetiology

 

Weakness of Tendoachilles

 

Usually neuromuscular

- Polio (Most common worldwide) 

- Spina bifida

- CP (can be due to overcorrection of T Ach)

- Spinocerebellar Degen (Friedreich's Ataxia)

- CMT

- Spinal dysraphism

 

Compartment Syndrome Deep Posterior 

 

Pathology

 

Imbalance of tendoachilles and dorsiflexors

- dorsiflexion of calcaneus

- moves insertions of T Achilles anterior

- further weakens the lever arm

 

Forefoot becomes flexed because of

- gravity 

- action of muscles during gait

- result is elevated longitudinal arch 

 

History

 

Difficulty walking 

Obvious deformity 

Shoe fitting & wear problems 

Painful callosities

 

Examination

 

Elevated longitudinal arch 

 

Prominent heel with abundant callus on plantar aspect 

- called pistol grip deformity 

 

Heel usually in neutral

 

Usually claw toes 

 

Xray

 

Lateral xray

- calcaneal pitch > 30o

- Meary's angle > 30o

 

MRI 

 

Exclude dysraphism

 

Management

 

Non-operative

 

Modification of shoe wear & orthoses required 

- cannot control deformity alone

- doesn't work

 

Operative

 

Age 0 - 5

 

Best avoided

 

Tendon transfer

- T Ant to T Achilles

 

Age 5-12

 

Grice arthrodesis STJ 

- extra-articular

- stabilise STJ

 

Transfer muscles

- must be > Grade 5 power

 

Options

- Tibialis anterior

- Tibialis posterior

- peroneals

 

Age >12

 

As Above

 

Triple arthrodesis

 

 

Cavo Varus

Background

Definition

 

A fixed equinus deformity of the forefoot in relation to the hindfoot 

- resulting in an abnormally high arch that fails to flatten with weight bearing

- deformity may be forefoot, hindfoot or combination

 

Foot CavusFoot Cavovarus

 

Aetiology

 

2/3 have neurological disorder

1/3 have CMT

 

Neuromuscular

Congenital

Traumatic

RA

Idiopathic

 

Muscle imbalance of intrinsics and extrinsics

 

1. Neuromuscular

 

A. Central 

- Friedreich's Ataxia (absent ankle jerks & balance)

- Cerebral Palsy

- Hydrocephalus

 

B. Spinal cord

- Spinal Dysraphism / spina bifida

- Diastematomyelia /Syringomyelia

- Spinal Cord tumours

- CMT Type 2 (degeneration of spinal axons)

 

C. Anterior horn cell

- Polio (imbalance between anterior and posterior m)

- SMA

 

D. Peripheral nerves (+roots)

- CMT type 1 (demyelinating peripheral neuropathy)

- Polyneuritis

 

E. Muscle Disease

- Muscular Dystrophy

 

2. Congenital

 

Congenital cavus foot

Residual clubfoot

Arthrogryposis

 

3. Traumatic

 

Compartment Syndrome

Malunion of fractured foot

 

4. Degenerative

 

OA / RA of hindfoot

 

5. Idiopathic

 

CMT / HSMN

 

Inherited disorder of nerves

- most common inherited neurological disorder

- heterogenous group

- characterised by weak muscles and abnormal sensation

- positive FHx

 

CMT 1

- most common 80%

- demyelinating disorder

- peripheral nerve roots

 

Symptoms

- glove and stocking parasthesia

- nil reflexes

- claw toes, cavus feet, stork legs

- loss of intrinsics in hand

- abnormal NCS

 

CMT 2

- second most common 20%

- primary axonal neuropathy

- degeneration of spinal axons

 

Symptoms

- normal DTR

 

CMT 3 / 4 / X 

 

Pathophysiology

 

Rang Tripod concept

- heel / MTPJ 1st / MTPJ 5th 

- all must touch ground

- if 1st MTPJ plantaflexed

- heel must move into varus

 

Imbalance is the key to understanding

- PL creates cavus and equinus

- TP creates varus

 

A.  PL > T Ant 

- equinus forefoot

- plantar flexed first ray

- cavus foot

 

B.  T Post > PB 

- varus

 

C.  Weak Intrinsics & EDL < FDL

- clawing

 

Deformity

 

A.  Cavus foot

 

PF 1st ray initially 

- weak T Ant

- EHL & EDL act to DF ankle

- this increases windlass mechanism 

 

Contracture of plantar fascia 

- fixed Cavus

- fixed navicular-cuneiform & 1st CMTJ

- holds MT plantar flexed

 

B.  Varus heel 

 

Causes 

 

1.  Overpowering T Post & long toe flexors

- T post may be primary deforming force

 

2.  Supination of forefoot due to PF 1st ray

- then need varus heel to place lateral column on floor with PF ray

- may be primary deformity

 

C.  Clawing of toes  

 

Weak intrinsics 

- unopposed flexors and extensors

- hyper-extended MCPJ +/- dorsal subluxation MTPJ's

- claw toes

 

D.  Ankle Instability

 

Weak P Brevis

- Loss of dynamic restraint

 

Varus heel increases inversion moment on ankle 

 

DDx

 

1.  Bilateral Cavovarus

 

Central Pathology

- Spinal Cord Tumour / Dysraphism

- CNS 

 

2.  Unilateral Cavovarus 

 

Peripheral or Local Pathology

- Polio

- clubfoot

- Incomplete spinal cord or Cauda equina trauma

- Deep posterior Compartment Syndrome

- Compartment Syndrome of Foot

 

3.  CalcaneoCavus

 

Hindfoot Cavus 2° DF of calcaneus only

 

The apex is the differential

- Midfoot Cavus has apex in tarsus

- Forefoot Cavus from PF of 1st Ray (form seen in CMT)

 

Stages

 

1. Flexible cavus / Flexible 1st MT

- plantarflexion corrects with pressure on 1st MT

 

Cavus FootCavus Foot Flexible First Metatarsal

 

2. Fixed 1st MT equinus / hindfoot mobile varus

- hindfoot corrects with Coleman block test

 

3. Fixed lesser MT's equinus / fixed hindfoot varus

 

4. Bony changes

 

History

 

Family history

 

Is it progressing?

 

Metatarsalgia

 

Lateral ankle sprain 

- secondary to hindfoot varus

 

Ulcerations due to clawing

 

Foot numbness

 

Difficulty shoewear

 

Examination

 

Goals

- aetiology

- define deformity / correctability

- motor drive to deformity

 

Look

 

Front

- dysmorphism

- stork legs

- shoes

- parents

 

Side

- cavus foot / plantar flexed first ray

- claw toes

 

Back

- varus heel

- signs spinal dysraphism

 

Walk

 

High stepping gait

- weak T Achilles

- drop foot

 

Back knee gait

- fixed equinus

 

Heel walk 

Toe walk

Squat

 

Coleman Block  / Lateral Block Test 

 

Technique

- block under lateral foot

- first ray touches the ground

 

Aim

- eliminate forefoot deformity

- if hindfoot corrects with this test the hindfoot is flexible

- forefoot surgery should be sufficient to correct hind foot

 

Foot

 

Toes

- Claw toes - ? correctable

- Plantar keratoses from uncovering MTPJ

- Dorsal toe corns from claw toes

 

Plantarflexed 1st MTPJ 

- ? correctable

 

Motor examination

- T Post / T Ant /  PB & PL

- Ankle DF & STJ Eversion weak 

 

Silverskiold

- is T Achilles tight ?

 

Neurology

- abdominal reflexes

- LL neurology

- CMT 1 abnormal sensation and absent reflexes

 

X-ray

 

Lateral x-ray

- sinus tarsi easily seen

- PF 1st ray

 

Meary's angle

- talo - 1st metatarsal angle 

- normal 0o

- increased in cavus > 30o

 

Calcaneal Pitch

- normally 20o or less

- > 30o abnormal

- will demonstrate hindfoot DF

- demonstrates calcaneovarus

 

Pes CavusCalcaneal Pitch

 

MRI spine

 

Exclude spinal dysraphism

 

NCS

 

Can help diagnose CMT

 

Neurology review

 

Management

Non Operative

 

Options

 

Metatarsalgia

- preMT dome

 

Claw toes

- wide deep toe box

 

Foot drop

- AFO

 

Insensate foot

- custom orthosis

 

Varus

- lateral heel wedge

- AFO (flexible)

- medial iron with lateral T strap

 

Ankle Orthoses

 

Operative

 

Pes Cavus Post Op

 

Indications

 

Difficulty with Footwear

Pain

Lateral instability 

 

Contra-Indications

 

Need to ensure is not progressing

- otherwise surgery will not work

- i.e. does patient need spinal surgery first for dysraphism

 

Options

 

Soft tissue surgery

- for dynamic / flexible deformity

 

Bony surgery

- for static / fixed deformity

 

Algorithm 

 

Stage 1 / Flexible 1st MT PF

 

Shoe modification

 

Stage 2 / Fixed 1st MT + Flexible Hindfoot

 

Steindler release (plantar fascia release)

Jones / 1st MT osteotomy

Lesser toes as necessary

T post transfer if weak dorsiflexion

PL to PB transfer if weak eversion

 

Stage 3 / Fixed 1st MT / Fixed Hindfoot

 

Above +

Lateral Shift Calcaneal Osteotomy

T Achilles lengthening

 

Stage 4 / STJ and other bony deformities

 

Triple arthrodesis

Tarsal / MT osteotomy

 

ForeFoot

 

Soft tissue

 

1.  Steindler Release / Plantar fascia release

 

Best < 8 years

- for cavus

 

Incision

- medial incision extending 1.5 inches anterior to calcaneal tuberosity

 

Dissection

- separate above and below fascia

- divide plantar fascia & Long Plantar ligament at calcaneum

- excise 1 cm of fascia

- NV lie between 1st & 2nd layers

- if stay on periosteum will avoid damage to NV

- lateral plantar nerve is at lateral edge of fascia

 

2.  Tibialis Posterior transfer

 

Indicator

- weak dorsiflexion

 

Technique

- through interosseous membrane to lateral cuneiform

 

3.  P Longus to Brevis transfer 

 

Removal of 1st ray PF & increase eversion

 

4.  First Toe / Jones Procedure

 

Indication

- great toe clawed

- MTP hyperextended and IP flexion

 

Technique

 

A.  Leave EDB to P1 intact

- will drive extension toes

 

B.  Harvest distal EHL

- pass through drill hole neck MT

- suture to itself

 

C.  Fusion of IPJ

- K wire

 

5.  Hibbs 

 

EDL transfer

- plug into middle cuneiform 

- act as DF instead of weak T Anterior

 

6.  Lesser Claw Toes 

 

A.  Girdlestone FETT if flexible

B.  Extensor Tenotomy / PIPJ fusion / MTPJ dorsal capsulotomy / Weil's osteotomy if fixed

 

Bony

 

1st MT osteotomy 

 

Description 

- dorsal closing wedge osteotomy

- extension osteotomy

 

Indication

- incomplete correction of first ray

- mature patient with closed physis

 

Technique

- dorsal closing wedge osteotomy

- base of MT

- leave plantar surface intact

- 3-4 mm wedge

- close osteotomy, fixation with K wires

- +/- 2nd and 3rd

 

Hindfoot

 

Soft Tissue

 

1.  Tendo achilles lengthening

 

Indications

- unable to reach plantigrade

 

Technique

- percutaneous

- 2 medial and one lateral to take out of varus

 

2. Lateral Ligament reconstruction 

 

If complain of ankle instability

 

Bony

 

1.  Dwyer lateral closing wedge Calcaneal osteotomy 

 

Indication

- correct fixed hindfoot varus 

 

Problem

- shortens foot further

 

2.  Calcaneal Lateral Shift Osteotomy

 

Lateral approach

- curve just behind peroneals

- homann in front of tenoachilles

- homann under calcaneum

 

Oblique osteotomy 

- 45o

- behind posterior facet

- osteotome

- open with lamina spreader

- split periosteum medially with osteotome

- this avoids damage to medial structures

- transfer laterally 1 cm

- may need to lengthen T Achilles

 

Fix with screw or lateral staple

 

3.  Midtarsal Osteotomy / V shaped

 

Indication

- fixed, difficult cases

 

Cole Osteotomy

- use ilizarov

 

4.  Triple Arthrodesis

 

For salvage of rigid deformity

 

Planovalgus Foot

Aquired Adult Flatfoot Deformity

Definition

 

Acquired Adult Flatfoot Deformity (AAFD)

- collapse of medial longitudinal arch

- secondary to ligament / tendon / joint or bony pathology

 

Classification

 

1. Congenital

 

Flexible / Physiological

 

Ligamentous Laxity (DIAL HOME)

 

Rigid 

- Congenital Vertical Talus 

- Tarsal Coalition

 

2.  Acquired

 

Tibialis Posterior Dysfunction

 

RA Flat Foot

 

Neurological

- Charcot Foot

- spinal dysraphism

- CP

- polio

 

OA

 

Midfoot OA / Lis Franc injury

 

Midfoot OA Planovalgus

 

Subtalar joint OA (calcaneal fracture)

Ankle OA

 

Ankle OA Valgus Tilt

 

Ligament

- isolated spring ligament rupture (rare)

- iatrogenic / traumatic plantar fascia rupture (rare)

 

Compensory to Rotational & Coronal plane deformities

- tibial torsion

- genu valgum

- ankle equinus 2° tight TA

 

Biomechanics of FlatFoot

 

Normal Gait / 3 phase rocker

 

1.  Heel Strike 

 

Tibia IR 

 

Hindfoot Everts

- unlocks TNJ & CCJ 

- forefoot pronates

 

Allows shock absorption by hind/mid/forefoot

 

2.  Stance 

- WB axis passes through ASIS to patella to middle of foot

 

3.  Toe Off

 

T Posterior "locks" the midfoot (i.e. the transverse tarsal joints)

- T Anterior inverts the hindfoot

- T Achilles plantar flexes the calcaneum

- Tibia externally rotates

 

Flatfoot Gait

 

The above components are exaggerated

- More stress on ligament structures

 

WB axis shifts medially, causing

- increased femoral anteversion

- internal knee rotation

- increased Q angle

 

T Achilles becomes evertor

 

Increased pronation

- may cause Hallux Valgus

 

Specific Conditions

 

Lisfranc Joint OA

 

Acquired Adult Flatfoot

 

Aetiology

 

1.  Post injury

 

Degenerative arthritis develops after fracture dislocation

- Acute injury often missed

- Adequate acute treatment may not prevent occurrence

 

2.  Idiopathic 

- not related to trauma

 

3.  Charcot

 

X-ray

 

Degenerative changes invariably involve second MT/ 2nd Cuneiform joint

- may involve 1st & 3rd joints

- rarely involves 4th & 5th joints

 

Midfoot AP Secondary to Missed Lis Franc

 

Non-operative

 

Moulded arch support / UCBL initially if correctable

Lateral Single Upright caliper with Medial T strap if not

 

Operative

 

Realignment of Lisfranc joint with arthrodesis

 

Rheumatoid Flat Foot

 

50% will get flat foot

- subtalar OA

- spring ligament attenuation

- tibialis post dysfunction

- progressive valgus deformity at hindfoot 

 

OA of Ankle Joint

 

Usually post traumatic

- valgus tilt of Talus leads to pronation of Talus & Calcaneus

 

Flatfoot def corrected when AJ realigned

 

Charcot Flat Foot

 

90% changes in hind and midfoot

- repetitive microtrauma in presence of neuropathy leads to microfracture

- 2° to Sensory & Autonomic Neuropathy

 

Progressive subluxation / collapse

 

Usually associated with Diabetes

- may be marked collapse

- develop bony prominence on medial sole

- may cause ulceration

 

Plantar Fascia Rupture

 

Traumatic or spontaneous

- pain at calcaneal origin

- palpable gap

- often 2° excess HCLA

 

Management

- arch support

- longitudinal arch will slightly flatten, but rupture should heal

 

Spring Ligament Rupture

 

Rare

- ? Repair

- probably in reality treat as for PTTD

 

 

Flexible Flat Foot

Symptoms

 

Complain of pain with prolonged standing

 

Complain feet tire easily

 

Examination

 

Adult Flatfoot Clinical Valgus Hindfoot Clinical

 

Overall alignment

 

Heel raises

 

Flexibility of Flat foot / STJ

 

T Achilles tightness

 

X-ray

 

Planovalgus Lateral XrayPlanovalgus Foot Meary's Angle

 

Meary's angle

- Talus - first MT angle

- lateral weight bearing view

 

Grading

- 0o normal

- mild - 15o

- severe  - 30o

 

Non Operative

 

Medial arch support

Medial heel raise

UCBL

 

Operative

 

Indications

- failure non operative measures

- inability to wear shoes

 

Surgery

 

1.  Evans anterior calcaneal osteotomy

 

Theory

- lateral column lengthening

 

Technique

- incision tip of fibula to base of 4th MT

- elevate EDB anteriorly

- peroneal tendons anteriorly

- sural nerve posteriorly

- identify CCJ joint but do not open capsule

- insert Homan retractor and identify interval between middle and anterior facet

- osteotomy between the two, 1.5 cm from CCJ

- insert lamina spreader, assess arch at this point

- insert tri-cortical iliac crest bone graft (slightly trapezoidal) with bone tamp

- 1cm opening wedge

- stabilise with plate or screws

 

Evans Osteotomy + MT Osteotomy + FDL transferEvans Osteotomy + MT Osteotomy + FDL transfer Oblique

 

2.  Medial reefing / repair spring ligament / FDL Transfer

- incision at inferior aspect head of talus

- above tibialis posterior tendon

- excise segment of spring ligament approximately 6mm

- reapproximate ligament with non absorbable sutures

 

3.  Medial Cuneiform Plantarflexing Osteotomy

 

Indication

- Restore weight bearing tripod

 

Technique

 

Dorsal osteotomy mid-substance cuneiform

- lever open with osteotome

- 4 - 7 mm tri-cortical graft

- fixation with 2 x screw

 

Post operative

- back slab

- wound check at 1 week

- sutures out at 2 weeks unless DM or RA

- SL POP for 6/52 NWB

- then WBAT in boot 6/52

 

4.  +/- T Achilles lengthening

- if unable to passively DF ankle past 10o with knee extended

 

Post op

- POP for 6/52 (mould into arch)

- arch support / UCBL for 6/12

 

Tibialis Posterior Dysfunction

Background

Aetiology

 

Intrinsic

- inflammatory

- degenerative

 

Extrinsic

- traumatic

- spur

 

Epidemiology

 

F > 40

 

Associations 60% of cases  

- hypertension

- diabetes

- obese

- trauma 

- prior surgery

- steroids

 

Aetiology

 

RA 

- flat foot also secondary to synovitis TNJ and STJ

 

Hypermobile flat foot

 

Seronegative disorders

- Ankylosing spondylitis / psoriasis / reiter's

 

Anatomy Tibialis Posterior

 

Origin

- posterior tibia, fibula and inter-osseous membrane

- acute angle around medial malleolus

- flexor retinaculum holds TP in groove 

- no mesotenon

- relative hypo-vascular zone 1-2cm distal to medial malleolus

 

Insertion

- navicular tuberosity

- plantar cuneiforms

- 2,3,4 MT

- sustentaculum tali

 

Excursion 

- 2cm only

 

Nerve Supply

- tibial nerve (L4/5, S1)

 

Action

 

1.  Runs medial to axis STJ

- inverts STJ & adducts forefoot

 

2.  Runs posterior to axis AKJ

- plantar flexor

 

3.  Maintains longitudinal arch

 

4.  Locks the midtarsal joints

- allows T Achilles to perform heel raise

- otherwise T Achilles acts at TNJ

 

Opposed mainly by peroneus brevis

 

Pathophysiology

 

Avascular zone 

- behind medial malleolus

- paratenon is supplied by blood vessels from a mesotenon on its post aspect

- tendon is composed of fibrocartilage where it changes direction around the med malleolus 

 

Tendon Changes

 

Starts with varying combination

 

1. Paratendinitis

- fluid in sheath 

- synovial proliferation

 

2. Tendinosis 

- tendon degeneration 

- tendon enlarged

- longitudinal splits develop 

- becomes yellowish 

 

Tibialis Posterior Tendinosis

 

3. Elongation of tendon

 

4. Rupture

 

5. Deformity 

- loss TP function leads to acquired Planovalgus

- initial deformity is collapse of medial longitudinal arch

 

Dysfunction

 

1. Medial arch collapses

2. STJ everts

3. Valgus heel

4. Foot abducts at TNJ

5. Achilles tendon acts as evertor when heel in valgus

6. Calcaneus impinges on fibular causing lateral AJ pain

7. Attenuation of TNJ capsule, spring ligament and deltoid ligament

 

History

 

Pain medially at first

- swelling

 

Lateral pain with impingement of fibula

 

Foot shape changes / progressive deformity

 

Difficulty wearing shoes

 

Examination

 

Any sign of RA

 

Look

- flattened medial arch

- valgus heel

 

Too many toes sign

- abducted forefoot

- > 2.5 toes

- more than on other side when in symmetrical posture

 

Single Heel Raise

- unable to heel raise

- need T Post to invert STJ & lock hind foot rigid so T Achilles can pull up Calcaneus

 

Sit over edge

- AKJ

- STJ

 

Feel

- tender medial

- is tendon thickened

- may be tender laterally

 

STJ

- fixed or flexible

 

AKJ

- fixed or flexible

 

T Achilles

- silverskiold

 

Power

1.  T Post with foot inverted in equinus

2.  Foot equinus and everted

- ask patient to invert the foot

 

NV examination

 

X-ray

 

Lateral weight bearing

 

Early 

- reduced talo-metatarsal angle (Meary's angle  0-10°)

- medial cuneiform to floor distanced reduced (N= 2.5cm)

- talus plantar flexed

 

Late

- STJ OA

 

AP weight bearing of foot and ankle

 

Early - abduction of forefoot with navicular lateral to talus

 

Late - ankle OA / TNJ OA

 

MRI 

 

Enlarged T Post - tendinosis

 

Thickned Tibialis Posterior

 

Torn T Post - half size of FDL

 

Johnson Classification

 

Stage 1 

- T Post tendonitis 

- no deformity

 

Stage 2 

- T Post rupture

- unable SHR

- foot remains flexible

 

IIA - minimal forefoot abuction

IIB - forefoot abducted throught THJ / > 30% uncovered

 

Stage 3 

- fixed deformity of STJ (may have STJ OA)

 

Stage 4 

- valgus angulation of talus & OA of ankle joint

 

 

Management

Surgical Algorithm

 

Stage 1 Tendonitis

 

Non-operative

 

Walking cast / NSAIDS

- 6/52

 

UCBL

- 3/12

- worn inside the shoe

- ends under malleoli

- controls the heel (which must be flexible)

- supports the arch

 

Operative / Synovectomy and debridement

(+/- FDL transfer and calcaneal osteotomy +/- T Achilles lengthening)

 

Stage 2  Tendon Rupture

 

Non Operative

- UCBL

 

Operative

 

2A - FDL transfer & calcaneal osteotomy +/- T Achilles lengthening

2B - + Lateral column lenthening to correct abduction

 

Stage 3 Rigid valgus hindfoot

 

Non Operative

 

Rigid AFO

Caliper: Outside iron with inside T strap

 

Operative

 

Triple arthrodesis

 

Stage 4 / Abnormal AKJ

 

Pathology

- valgus angulation of talus

- deltoid ligament gone 

- early degeneration of ankle joint

- degenerative changes in subtalar & midtarsal joints 

- valgus angulation of talus

 

Non Operative

- double metal uprights with PTB

 

Operative

- pan talar fusion 

 

Operations

 

Tibialis Posterior Synovectomy and Debridement

 

Position

- supine on table

- foot falls into ER

- tourniquet

 

Incision

- tip of medial malleolus to navicular

- open tendon sheath

- often fluid and synovitis

 

Synovectomy

 

Repair any fissures

 

Inspect insertion

- if partially avulsed

- FDL transfer

 

Close tendon sheath

 

S/L cast for 3/52

 

Results

- 75% good results

 

Calcaneal Osteotomy / Medial Calcaneal slide

 

Aim

- shifts calcaneum medially

- reduces valgus thrust on hindfoot

- pull of gastoc/soleus is medial to STJ

 

Indications

- stage 1 or 2

- in combination with FDL transfer

 

Timing

- perform osteotomy first, then tension FDL

 

Set up

- sandbag under ipsilateral hip

- table rolled over to expose lateral heel

- then unroll bed to expose medially

 

Calcaneal Sliding Osteotomy LateralCalcaneal Sliding Osteotomy Harris Axial

 

Incision

- lateral incision

- in line with peroneal tendons

- need to protect sural nerve posteriorly

 

Osteotomy

- protect peroneals

- protect T Achilles

- behind posterior facet STJ

- transverse osteotomy at 45o to plane of foot

- complete with osteotome to protect medial structures

- use osteotome to gently break up periosteum

- use lamina spreader to break up final adhesions

- translate 10mm medially

 

ORIF

- K wire lateral to T Achilles, towards CCJ

- check II, 6.5 mm partially threaded cannulated screw

 

Lateral column lengthening

 

Indications

- midfoot abduction

 

Technique

- anterior calcaneal ostetomy

- insertion bone graft wedge

- stabilisation plate or screws

 

FDL transfer 

 

Reasons

- FDL easily found by reflecting abductor hallucis

 

Indications

- foot should be supple with no fixed deformity 

- stage 1 / 2

 

Incision 

- along entire length T posterior

- 10 cm proximal to medial malleolus

- to metatarsal cuneiform joint

 

Superficial dissection

- expose T posterior in sheath

- may be ruptured, avulsed, deficient, fissured

 

Deep dissection

- abductor hallucis reflected plantarward

- find fat / Knot of Henry

- release Master Knot of Henry 

- crossover of FDL & FHL 

- FDL plantar to FHL

- suture together and release proximal FDL 

 

TNJ

- open to visualise

- 4.5mm drill hole through navicular

- Reinsert FDL into underside of navicular

- plantar to dorsal

- pulled tight with ankle in equinus & forefoot in varus 

- close TNJ capsule

- No need to attach proximal T Post to FDL

 

Repair spring ligament

 

Closure abductor fascia

 

Post op

- 6/52 in equinus and inversion NWB

- x-ray to check osteotomy has healed

- 4/52 weight bearing in removable cast with ROM exercises

- may need physio

 

Triple Arthrodesis

 

Indication

- fixed hindfoot deformity with lateral joint pain

 

Aim

- realign hindfoot

- plantigrade surface

- maintain integrity of adjacent jts

- avoid neuromas

 

Issues

 

1.  Fuse TNJ first 

- this should passively align STJ

- need medial approach to reduce TNJ

 

2.  Fuse STJ 

- slight valgus not neutral or varus

- lateral approach

- may need large lateral bone wedge

- may have issues with lateral skin closure

 

 

Plantar Fasciitis

Definition

 

Pain at attachment of thickened central part of plantar aponeurosis to Medial Calcaneal Tuberosity

 

Anatomy Plantar Fascia

 

Origin 

- medial calcaneal tuberosity

 

Inserts 

- 5 bands superfical & deep layers

 

Superficial

- insert transverse MT ligament & skin

 

Deep 

- flexor sheath, volar plate & periosteum of P1

 

Action

- when toes passively DF in toe off

- inelastic

- stabilises and elevates arch of foot

- windlass mechanism

 

Fat Pad 

- absorbs 20-25% of force at heel strike

- U-shaped, fat arranged in fibro-elastic septa

 

Epidemiology

 

Usually middle-aged male

- age 40-70 years

- M:F = 2:1

- usually unilateral

 

Predisposing factors

- obesity

- certain occupations i.e. Policeman's heel

- athletes and repetitive stress

 

Aetiology

 

Usually idiopathic

 

May be associated condition especially if bilateral

- Reiter's Disease

- Ankylosing Spondylitis (enesopathy)

- Gout

 

Pronated feet / cavus feet / planus feet

Obesity

Tight tendoachilles

 

Theories

 

1.  Degenerative change fat pad most common finding 

- decreased ability to cushion heel

 

2.  Injury to windlass mechanism with micro trauma

 

3.  Nerve entrapment

 

4.  Heel spur present in 50% with heel pain

- spur is in origin FDB (short flexors) not plantar fascia

 

Shmokler 1000 patients

- 13.2% incidence heel spurs

- 5.2% of which had heel pain

 

Williams

- 45 patients 52 painful heels

- 75% painful heels with spur

- 65% opposite heel had spur

 

Foot Calcaneal Spur

 

Pathogenesis

 

Degeneration 80% 

 

Repetitive stress at attachment

- leads to microscopic tears & cystic degeneration

- maybe periosteal reaction & spur formation

 

Entrapment 20%

 

Nerve Entrapment Syndrome

- lateral plantar nerve / Baxter's nerve

- mixed motor and sensory

- motor to abductor digiti minimi

- runs superior to plantar fascia

- may be compressed by spur or fascia

- difficult to diagnose

 

History

 

Pain at inferomedial aspect of heel

- worse when first rising from bed

- worse with prolonged standing or extreme exercise

 

Examination

 

Local tenderness at inferomedial aspect of Calcaneal tuberosity

 

Pain aggravated by passive dorsiflexion of toes

 

Tinel's sign

 

Cavus / Planus

 

Tight T Achilles

 

X-ray

 

Maybe calcaneal spur (50%)

- exclude tumour & infection

 

Bone Scan

 

Can be useful in atypical presentations

 

MRI

 

Show compression of 1st branch of lateral plantar nerve

 

DDx

 

Inferior heel

- calcaneal stress fracture

- fat pad atrophy

- calcaneal apophysitis

- nerve compression / tarsal tunnel

 

Posterior heel

- Achilles tendonitis

- retrocalcaneal bursitis

- STJ OA

 

NHx

 

80-95% settle with non-operative management

- in 6-12/12

 

Management

 

Non-operative

 

Acute cases respond better to HCLA

Chronic better to orthoses

 

Soft Heel Cup with Instep

 

Physiotherapy

- T Achilles stretches

- Plantar fascia stretches

- can rolling

 

Orthoses

- well padded running shoes

- viscous heel cushions + longitudinal arch support

- Soft Heel Cup with Instep

 

Night splint 

- hold in 15o DF

- very effective

- maintain night-time stretch

 

NSAIDS

 

ECSW

 

Aqil et al. CORR 2013

- meta-analysis of RCTs

- safe and effective treatment

- effects evidence at 12 weeks, last up to 12 months

 

High energy ECSW v low energy ECSW

- evidence for both

 

Cast immobilisation 

- keeps plantar fascia under constant stretch and minimises microtrauma

- patient should undergo this treatment before consideration for surgery

- very effective treatment

 

Injections

 

Cortisone

- ? US guided

- max 2 (plantar fascia can rupture)

 

PRP

 

Acosta-Olivo et al. J Am Podiatr Assoc 2016

- RCT of cortisone v PRP

- equally efficacious

- no between group difference

 

Botox

 

Ahmed et al Foot Ankle Int 2016

- RCT of saline v Botox

- significant improvement in botox group

 

Operative

 

Indication

- must have minimum 12 months non-operative treatment

- 5% of patients

- results of surgery variable

 

Results

 

Contompasis

- 129 patients

- 43% complete improvement

- 38% some improvement

- none worse off

 

Open Release of Plantar Fascia

 

Set up

- tourniquet

- prone / lateral / supine

 

Incision

- medial longitudinal incision

- this is often vertical in line with posterior border medial malleolus

- protect medial calcaneal branch 

 

Dissection

- divide ABHB fascia

- reflect this superiorly

- identify plantar fascia origin from tuberosity

- FDB is above plantar fascia

- insert homan retractors above and below

- lateral plantar nerve deep to abductor, above FDB laterally

 

Resection

 

Resect medial rectangle of plantar fascia

- divide 3/4 of fascia

- don't release in full unless very old and decrepit

- take 6 deep by 2 mm thick rectangle

 

+/- neurolysis

 

+/- Resect spur

- reflect FDB

- remove with osteotome / nibbler

 

B.  Endoscopic release

 

Ogilvie-Harris Arthroscopy 2000

- 53 patients with 65 feet

- complete resolution of pain in 89%

- 71% returned to unrestricted sport

 

Results

 

Cochrane Review 2012

- no evidence for laser or ultrasound

- limited evidence for dorsiflexion night splints

- limited evidence topical corticosteroid

- some evidence for injected CS

- equivocal for ECSW

 

Rheumatoid Foot

Forefoot

Issues

 

1.  Painful Bunion / Hallux valgus

 

Rheumatoid Forefoot Hallux Valgus

 

2.  Metatarsalgia / MTPJ dislocation

 

Rheumatoid Foot

 

3.  Claw toes

 

Claw Toes

 

Pathology

 

Earliest manifestation is synovitis of MTPJ 

- capsular destruction 

 

Dorsal subluxation MTPJ

- claw toes develop (MTPJ hyperextended, PIPJ flexed)

 

Plantar fat pad displaced distally

- MT heads exposed to plantar skin

- corns develop over PIPJ & under MT heads

 

Management

 

Non-operative Management

 

Shoe-wear modification

 

Extra-depth shoe / low heel / roomy toe-box

Custom-made arch support

Pre-MT dome for metatarsalgia

Heel cup to prevent heel valgus

STJ - single lateral upright with medial T strap

AKJ - double upright with square ferrule

 

Operative Management

 

Indications

 

Continuing pain

Increasing deformity

Footwear modification failure

 

Issues

 

Poor wound healing

Infection

Non-union

Recurrence of deformity

 

Timing in multiple joint surgery

 

Forefoot often first

- eliminates pedal sepsis

 

Hallux Valgus / Rigidus

 

Options

- arthrodesis

- arthroplasty

- Keller's procedure

 

Arthrodesis

 

Rheumatoid Forefoot Fowlers MTPJ Fusion

 

Procedure of choice

- provides forefoot power & buttresses lesser toes

 

Contra-indication

- involvement of IPJ 

- need to have mobile IPJ to put tip of toe onto the ground

- consider arthroplasty

 

Complication

- non-union

- malposition

- stress transfer to IPJ

 

Silicone Arthroplasty / Double-Stemmed Swanson

 

Indication

- low-demand patient

- IPJ of hallux affected

 

Complication 

- breakage

- silicone synovitis

 

Keller's Procedure

 

Indication

- in low demand patient where bony union expected to be difficult

- salvage procedure

 

Complication

- cock up deformity

- transfer metatarsalgia

- loss of power

- recurrence

 

Metarsalgia

 

Options

- synovectomy

- Weil's osteotomy

- Fowler's procedure

 

Synovectomy

 

Indication

- early disease / synovitis

 

Technique

- 3 incision

- one over first MT

- 2 between 2/3 and 4/5

- incise extensor hood

 

Weil's Osteotomy

 

Indications

- enlocated MTPJ

- i.e. in conjuction with treatment of claw toe

 

Technique

- transverse osteotomy

- MT head moved proximally

- secured with screw

 

Fowler's operation 

 

Fowlers

 

Indication

- dislocation MTPJ

 

Concept

- cascading excision of II - V MT heads 

- 2nd 3 mm longer than 1st or 3rd

- 3rd 3mm longer than 4th

- 4th 3 mm longer than 5th 

 

Technique

 

Single dorsal transverse skin excision just proximal to toe webs 

- can be performed via transverse plantar ellipse

- with severe dislocation may be easier to approach through plantar aspect 

- MT heads subcutaneous & NV bundle usually subluxed dorsally

 

Extensor tenotomy

 

MT heads excised in gentle curve

- dorsal distal to plantar proximal

- contoured on plantar surface to give rounded surface

- very little length removed from 5th MT 

- must not leave bony fragments in weight bearing pad

 

Second incision on plantar surface 

- proximal to MT heads

- ellipse of skin only excised 

- closed to pull skin of forefoot under MT ends

 

Claw toes

 

EPL lengthening / EDB tenotomy / PIPJ fusion

 

 

General Concepts

Definition 

 

Disorder of immune system 

- antigen-antibody complexes

- stimulate release of proteolytic enzymes

- leading to vasculitis, synovitis and cartilage destruction

 

Characterised

 

Articular Effects

- synovitis

- ligamentous and capsular laxity

- cartilage destruction

- osseous erosion

 

Vasculitis

- rheumatoid nodules

- digital ischaemia

- skin ulceration

- poor wound healing

 

Neuropathy 

- mononeuritis multiplex

 

General

 

90% will have foot problems

 

Forefoot

 

Most commonly involves forefoot

- 10x more common than hindfoot

 

1.  Hallux Valgus

2.  Dorsal Subluxation MTPJ

3.  Clawing of toes

 

Midfoot

 

TNJ OA

 

Hindfoot

 

STJ > AKJ

 

A.  STJ / Planovalgus (50%)

- destruction of soft tissues especially STJ capsule and interosseous ligament

- + Destruction of TNJ 

- leads to Planovalgus foot

- May be initiated or exacerbated by rupture of Tibialis Posterior (common)

- hindfoot valgus leads to T Achilles contracture

 

B.  Ankle

- Rarely affected (10%)

- Destroyed Ankle rarely occurs in isolation

- i.e. typically would have pan-talar arthritis

 

Management

 

Multiple Joint Surgery Timing

 

1.  Forefoot OT

- great symptomatic relief

- minimal patient stress

- eliminates pedal sepsis

- wound problems common & occur before prostheses implanted

 

2.  THR 

- easier to rehabilitate following THR with deformed knees

- allows correction of proximal limb contractures & lordosis

 

3.  TKR

 

4.  Hindfoot OT

- usually for planovalgus

 

Pre-operative

 

Vascular assessment

- ABI > 0.7

- ankle pressure > 90 mmHg

 

Examine for neuropathy

 

Medications

- stop MTX

- ? stop steroids

 

Infection prevention

- clean skin meticulously prior to surgery

- repeat in OT

- prophylactic ABx for 72hrs

 

C spine x-ray

 

Post operatively

 

Leave sutures in for 3/52 due to delayed healing on steroids

- elevate feet for 2-3/7 post-op

- change dressing that evening if large drainage or oedema

 

 

 

Midfoot / Hindfoot

Midfoot

 

A.  Lis Franc Joints OA

 

May cause flat foot

Treat with midfoot fusion

 

Rheumatoid Foot APRheumatoid Midfoot OA

 

B.  TNJ OA

 

May be affected in isolation early

- may cause passively correctable valgus foot

- UCBL insert

 

Talonavicular Arthrodesis

 

Indication

- erosion confined to this joint

- correct valgus deformity

 

Technique

- dorsomedial incision

- protect saphenous nerve and vein

 

Result

- will lose 80% STJ motion

 

Rheumatoid TNJ Fusion LateralRheumatoid TNJ Fusion AP

 

Hindfoot

 

A.  Tendo Achilles Insertional Tendonitis

 

Ankle Synovitis

 

Rheumatoid involvement of bursa at T Achilles insertion

- nodules may develop within the tendon

- can weaken attachment & precipitate rupture

 

Treatment

- excision of nodules

- may need tendon augmentation / reconstruction

 

B.  Retrocalcaneal Bursitis

 

Common

- heel lift initially

- may need debridement and excision of posterosuperior calcaneal prominence

 

C.  Tibialis Posterior Tendonitis /  Rupture

 

Synovitis of sheaths of T post & Peroneal tendons common

- treat with tenosynovectomy

 

Rupture of TP with flatfoot

- FDL transfer in Stage 2 

- triple arthrodesis in Stage 3

- pan talar arthrodesis in Stage 4

 

D.  Planovalgus

 

Causes

- STJ OA

- TNJ OA

- tibialis posterior rupture

- synovitis and rupture of the talocalcaneal interosseous ligament

- tight T Achilles

 

Pathology

- subtalar joint valgus angulation

- talar head drops into plantarflexion

- navicular subluxes laterally

- get planovalgus foot with forefoot abduction

 

Non Operative

 

Brace

- double upright with square ferrule

 

Operative

 

Triple Arthrodesis

 

Indication

- fixed painful hindfoot

- TNJ and STJ OA

- AKJ preserved

 

F.  AKJ OA

 

Total Ankle Replacement

 

Attractive concept

- reduces loading across other joints

- results similar to OA

 

Ankle Arthrodesis

 

Treatment of choice

 

Complicated by

- prolonged period to union  - 6/12

- non-union in 10%

 

Talus

OCD

DefinitionTalus OCD MRI Coronal

 

Fracture talus through articular cartilage into subchondral bone

- 2° force transmitted from distal tibia

 

Osteochondritis dissecans v osteochondral fracture

 

Epidemiology

 

6% ankle sprains

Average age = 25 

M > F

 

Location

 

1.  Anterolateral 50% 

 

Talus OCD Anterolateral FragmentTalus OCD Anterolateral 2

 

2.  Posteromedial 50% 

 

Talus OCD MedialAnkle OCD Medial

 

Aetiology

 

30% associated with other injuries

- medial and lateral malleolar fractures

- ankle sprains

 

A.  Traumatic / anterolateral

 

2° to inversion injuries

- will usually heal

 

B.  Atraumatic / posteromedial

 

2/3 caused by trauma

- 1/3 no history trauma 

- are chronic and won't heal 

 

Non-traumatic causes

- ? AVN 

- 20% bilateral (can be asymptomatic)

- some patients have multiple joints with OCD

- can have family history of talus OCD

 

Pathology

 

Start as acute intra-articular fracture

 

Bony fragment may

- revascularise & unite

- undergo AVN & not unite

 

Overlying cartilage may degenerate

 

Cyst may develop under fragment

 

Berndt & Harty Xray Classification

 

Stage 1 

- subchondral compression fracture

 

Stage 2 

- partially attached osteochondral fragment / flap

 

Stage 3 

- fragment detached in-situ / not displaced

 

Talus OCD Medial Type 3

 

Stage 4 

- detached displaced fragment

 

Talus OCD Medial Type IV

 

MRI 

 

Determine stability of fragment

- stable lesion has intact overlying cartilage

- unstable lesion has fluid at fragment-crater interface

 

Stage 1

- stable

- no detachment, no synovial fluid

 

Stage 2

- partially detached, some synovial fluid

 

Talus OCD Type 2

 

Stage 3

- completely detached, not displaced

 

Talus OCD Anterolateral MRI0001Talus OCD Anterolateral MRI0002

 

Talus OCDTalus OCD

 

Stage 4

- displaced

 

History

 

Lateral ankle sprain from inversion injury

 

Chronic symptoms after ankle sprain settled

- activity-related pain, stiffness & swelling

- crepitus, instability & locking (true locking rare)

 

Symptoms of lateral ligament instability

 

Examination

 

Tenderness around ankle joint

 

Pain with dorsiflexion / eversion

 

Decreased ROM, especially dorsiflexion

 

Effusion

 

Test for ligament instability

 

DDx

 

Chronic ligament instability

Lateral gutter ST impingement

Calcaneal fracture

Lateral process fracture

Tarsal coalition

Sinus tarsi syndrome

  

Management

 

Non Operative

 

Higher success with acute injury

- POP & NWB 6/52

- progressive to weight bearing over 3 - 4 months

 

Tol et al Foot Ankle Int 2000

- meta-analysis

- 14 studies with 201 patients

- 45% success rate

 

Operative

 

1.  Percutaneous Drilling

 

Indication

- Type 1, 2

 

Ankle OCD ArthroscopyAnkle OCD Percutaneous Drilling 1Ankle OCD Percutaneous Drilling 2

 

2.  ORIF

 

Indications

- acute

- large type 2 , 3

- in situ but unstable and not healing

 

Approach

 

A.   Lateral lesion

- approached through anterolateral approach

- ± Fibular osteotomy if large 

 

B.  Medial lesion

- approached through anteromedial approach

- ± medial malleolar osteotomy

 

Medial Malleolar Osteotomy

 

Technique

- partially displace

- debride base

- insert bone graft as paste

- fix with bioabsorbably headless compression screws

 

3.  Excision / curettage / abrasion / microfracture

 

Indications

- small lesion

- fragment detached with chondral lesion

 

Results

 

Tol Meta-analysis

- 88% success stage 3 and higher

- less if no curettage or dilling

- can do so arthroscopically

 

Ankle Scope OCD Grade 4Ankle Scope OCD Abrasion

 

Talus Chondral LesionTalus OCD Bleeding

 

4.  Allograft

 

Indications

- large lesions

- > 1cm diameter and > 5mm thick

 

Post operative

- PTB brace 1 year

 

Results

 

Gross Foot Ankle Int 2001

- 3/9 resorbed

 

4.  Osteochondral autograft / mosaicoplasty

 

Indications

- stage 4 lesion

 

Donor Site

- taken from knee NWB surface

- allograft

 

Technique

- fresh frozen talus

- 6.5 mm chisel used to take 10 mm plug

- medial malleolar osteotomy

- 6.5 mm drill into OCD site with drill guide, over drill 4 mm

- dilator

- insert plug, countersink 1 - 2 mm

 

Talus MosaicplastyTalus Mosaicplasty 1Talus Mosaicplasty 2

 

Results

 

Management Algorithm

 

Stage 1

 

Restricted activity / watch to see if heals

 

Stage 2 

 

Symptomatic 

- SL POP for 6/52 

- Successful in 90%

 

Failure

1.  ORIF

2.  Removal of necrotic fragment & drill base 

 

Stage 3 

 

Surgery probably indicated as very unstable

- ORIF

 

Stage 4 

 

Surgery

- acute ORIF if possible (i.e fragment is replaceable)

- chronic may have to discard fragment 

- manage chondral defect / abrasion

 

Talar Body Fracture

Definition

 

Body Fracture

- fracture line exits inferior surface behind lateral process

- into posterior facet

- intra-articular body fracture

 

Neck Fracture

- fracture line exits inferior surface anterior to lateral process

- in front of sinus tarsi

- extra-articular neck fracture

 

Types

 

1.  Shear

2.  Crush

3.  Posterior Process

4.  Lateral Process

5.  Talus Head

 

1.  Shear

 

Boyd & Knight classification

- coronal or sagittal 

- horizontal

 

Epidemiology

 

13-20% of all talus fractures

 

Issues

 

Involves both AJ and posterior facet STJ

 

CT Talar Dome FractureCT Talar Dome Fracture 2

 

Prognosis

 

A.  50% develop post-traumatic arthritis

 

B.  25-100% AVN

- Usually patchy and so avoid collapse

 

Management

 

Undisplaced

- POP

 

Displaced 

- ORIF 

- either medial or lateral approach

- may need medial or lateral malleolar osteotomy

 

Talar Dome ORIF APTalar Dome ORIF Lateral

 

Talar Dome ORIF APTalar Dome ORIF LateralTalar Dome ORIF Non Union

 

Nonunion

 

Talus Body Nonunion CTTalus Body Nonunion CT2Talus Body Nonunion MRI

 

Talus Body Nonunion ORIF 1Talus Body Nonunion ORIF 2

 

2.  Crush

 

High energy

- associated injuries common

- prognosis as above

 

Management

- as above 

 

3.  Posterior Process Fractures

 

Anatomy

 

Composed of Posterolateral & Posteromedial tubercles

- separated by sulcus for FHL

- lateral larger than medial 

 

PL tubercle

- size variable

- Superior surface non articular, attaches PTFL

- Inferior surface in continuity with posteror articular surface of Talus

 

PM tubercle

- also varies in size

- deep & superficial Deltoid ligaments attach

 

Os Trigonum

- accessory bone seen in association with PL tubercle of talus

~ 50% of feet

- may be unilateral or bilateral

- may be fused to talus or calcaneus 

- relationship to PL tuberosity varies from complete separation to fusion

 

Os TrigonumTalus Posterior Tubercle Synchondrosis

 

Mechanism

 

A.  Forced PF 

- impingement especially ballet / soccer

 

B.  Excess DF 

- increased tension on PTFL with avulsion

 

Examination

 

Tender posteriorly

Crepitus with PF

Pain with motion of Hallux in groove

 

DDx 

 

Lateral process fracture

Fracture of fused os trigonum

Disruption of synchondrosis of os to talar body

 

Investigation

 

Xray

 

Talus Posterior Process Fracture

 

Bone Scan / CT useful in Dx

 

Talus Posterior Process Fracture CT

 

Managment

 

Same for medial & lateral

- conservative initially

 

Persistent symptoms >6/12 

- excision of fragement

- posteromedial or posterolateral approach

- Persistent problems from non-union not uncommon 

 

4.  Lateral Process Fractures

 

Talus Lateral Process FractureTalus Lateral Process Fracture CT

 

Eponymous name

 

Snowboarder's fracture

 

Anatomy

 

Wedge shaped prominence

- most lateral aspect of talar body

- point of attachment of lateral talocalcaneal, cervical, bifurcate & ATFL

- fracture involves talofibular and STJ

 

Mechanism 

 

Acute dorsiflexion & inversion of foot

- most are avulsion fracture

 

Clinical

 

Identical to lateral ankle sprain

 

X-ray

 

Best seen on mortise view

 

Lateral Process Fracture

 

Management

 

Depends on size and displacement

 

1.  Large and non displaced

- non operative

 

2.  Large and displaced

- ORIF

 

3.  Comminuted

- non operative

- excise if problematic 

 

5.  Talus Head Fractures

 

Talar Head FractureTalar Head Fracture CT

 

Epidemiology

 

< 10% of all talus fractures

- rare

- often missed

 

Pathology

 

Disability via involvement articular surface 

- late TNJ arthritis

- associated with subluxation / dislocation of transverse tarsal joints

 

Types

 

1. Compression fracture

- impaction injuries with force through navicular to compress head

- hyperdorsiflexion

- may also produce compression fracture of navicular

 

2. Shear fracture

- secondary to inversion injury

- causes midtarsal adduction with navicular tearing off portion head

 

Management

 

Non-displaced 

- cast NWB

 

Displaced 

- ORIF via medial approach

- if extremely comminuted consider TNJ arthrodesis

 

Talar Neck Complications

AVN  

 

Largely related to degree of displacement

 

Incidence

 

Hawkins Type I

- 0% to 13% 

 

Talus AVN Hawkins 1

 

Hawkins Type II 

- 20% to 50% 

- usually only patchy and not a problem (rarely collapses)

- usually unites 

 

Hawkins Type III / IV

- 90% to 100% 

- often a problem

 

 Talus AVN Post ORIF

 

Talus AVN 1Talus AVN 2

 

Hawkins Sign 1970

 

Means talus is vascularised

- makes diagnosis of AVN unlikely

 

AP view

- at 6 - 8 weeks see disuse atrophy of bones

- due to NWB

- thin rim of radiolucency under cartilage of talar dome

- subchondral atrophy

 

MRI 

 

Best method to diagnose AVN

 

Talus AVN MRI

 

CT

 

Talus ACN CT 1Talus AVN CT 2

 

NHx

 

Usually posterolateral corner

- furtherest from medial blood supply

 

Collapse occurrs despite years of NWB

- NWB does not prevent collapse 

 

Creeping substitution can take up to 36 months

Collapse in most is well tolerated

Hawkins advocates weightbearing once united as re-ossification takes years

 

Management Limited collapse with OA

 

Arthrodesis of the affected joint

 

Management Complete collapse

 

Issue

- have a dead talus

- very difficult to obtain tibio-talar-calcaneal fusion

 

1.  Blair fusion / tibio-talar arthrodesis / sliding anterior tibial graft

 

Ankle Blair Fusion APAnkle Blair Fusion Lateral

 

Advantage

- maintains length

 

Anterior approach between EDL and EHL

- excise avascular body

- use saw to take 5 x 2.5 cm graft anterior tibia

- slide graft from distal tibia

- insert into notch in residual viable talar neck and head

- foot in 0o DF, 5o valgus, 10o ER

- single screw x graft into tibia

- additional tibio-talar scrws

- Pack cancellous bone grafts around the fusion site.

- Apply a long leg cast with the knee flexed 30o

 

Results

- 4 united, 3 pseudos

- 5 good, 1 fair, 1 poor

 

2.  Pantalar fusion with IM nail

 

3.  Ilizarov Tibio-calcaneal Fusion 

 

Disadvantage talus excision

- makes leg short

- 3cm short on average

 

Technique

- frame tibio-calcaneal fusion

- Ilizarov proximal corticotomy and lengthening

 

Mal-union 

 

Incidence

 

More of a problem than AVN in Type II 

- may be up to 40%

- most common with non operative or single incision operations

 

Issue

 

Varus secondary to medial comminution

- creates cavus foot with supination

- walk on lateral border of foot / walk with IR foot

- predispose to premature OA

 

Options

 

1.  Talus osteotomy

2.  Medial column lengthening with tri-cortical graft

3.  Lateral column shortening

 

Arthritis

 

Subtalar joint arthritis

- most common complication

- rarely requires fusion

 

Non operative

 

STJ 

- UCBL

 

Ankle 

- moulded AFO

 

Operative

 

Fusion

 

Delayed Union 

 

Definition

- > 6 months

- incidence is 10%

- very common

 

Non-union

 

Definition

- >12 months

- rare

Talar Neck Fracture

Epidemiology

 

Second most common  hindfoot after calcaneal fractures

 

Aetiology

 

Aviators Astragalus

 

Fall from height

- hyper-dorsiflexion injury

- neck of talus strikes the anterior tibia

 

Anatomy

 

More than half surface covered by articular cartilage

- medial articular wall straight

- lateral articular wall curves posteriorly

- meet at posterior tubercle

 

Neck of talus

- medially 10 - 44o from axis of body

- plantar 5 - 50o

 

No muscle or tendon attachments

 

Ligaments

- deep deltoid medially

- ATFL, PTFL

- FHL tendon in groove posteriorly

- head supported by spring ligament (CN ligament)

 

Facets

- posterior / middle / anterior

- correspond to calcaneal facets

- sinus tarsi between posterior and middle

 

Blood Supply

 

3/5 talus covered by articular cartilage

- blood can only enter through 2/5

 

1.  Posterior tibial / artery of tarsal canal

- main supply to body

- branches to deltoid ligament

- enters talar neck and supplies most of body

 

2.  Anterior tibial / Dorsalis pedis

- supplies head and neck

 

3.  Peroneal / artery of tarsal sinus

- supplies head and neck head and neck

 

Pathology

 

Often with rotation 

- with DF body of talus locks in mortice 

- fracture neck on tibia

- remainder of foot displaces medially thru STJ 

- disrupt inter-osseous and lateral / posterior ligaments 

- dislocation of STJ and AKJ 

 

Body of talus is forced out postero-medially swinging on intact deltoid

- comes to lie posterior to medial malleolus & anterior to T achilles

- often associated medial +/- lateral malleolus fracture

 

Classification Hawkins 1970

 

1.  Undisplaced fracture

 

Fracture of neck between posterior and medial facet

- precluded by any displacement of 1 - 2 mm

- may need CT to confirm

- means only one blood supply is disrupted

 

AVN 10%

 

2.  Subluxation / dislocation STJ

- subluxed posteriorly or medially

- blood supply through neck and in canal disrupted

- blood supply through medial body usually maintained

 

AVN 39% Vallier et al JBJS Am 2004

 

Talar Neck Fracture

 

3.  Subluxed STJ &  AKJ 

 

Body extruded postero-medially

- head maintains relationship with navicular

- 25 % open 

- all three blood supplies are disrupted

 

Talus Fracture Type 3

 

AVN 67% Vallier et al JBJS Am 2004

 

4.  Type 3 + subluxed TNJ

 

Dislocation of head and neck

- poor outcome

- significance is that blood supply to head may also be disrupted

 

AVN 90 - 100%

 

Hawkins 4 Talar Neck FractureHawkins 4 Talar Neck Fracture AP

 

Examination

 

Open wounds

 

Compound Talus

 

Skin under threat (Type III / IV)

 

NV compromise

- fragment can compress circulation

 

X-ray

 

Canale view

- evaluates talar neck

- foot 15o pronated

- beam angled 75o to foot

- look for medial shortening / varus

 

CT

 

Management

 

Non-operative

 

Indication

 

Only for true type 1 injuries

 

Technique

 

Frequent review to prevent loss of position

SL NWB POP 6/52

 

Operative Management

 

Goal

 

Anatomic reduction

- rotation / length / angulation of talar neck

 

Any displacement of 2mm

- increases contact stresses of STJ

- leads to premature STJ OA

 

Closed Reduction

 

Occasionally need to do closed reduction

- pressure on skin

- vascular compromise

- patient severely injury

 

Technique

- flex knee to relax gastrocnemius

- traction on plantarflexed foot to realign head and body

- varus / valgus correct as required

- place temporary percutaneous K wires

 

Timing of Surgery

 

Does early reduction prevent AVN?

 

Vallier et al JBJS Am 2004

- 102 patients

- no evidence that surgical delay increased AVN

- AVN associated with neck comminution and open fractures

- recommend is reasonable to wait for swelling to subside

 

Sanders 2004 JBJS Am

- similar conclusion

- 29 patients

- delay in surgery did not affect union or AVN rates

 

Surgical Technique

 

1.  Closed Type 2 - 4

 

Position

- supine on radiolucent table

- tourniquet, IV Abx, II available

 

Incisions

- 2 incision technique

 

Anteromedial 

- just medial to T anterior tendon 

- begin at TNJ

- can extend to MM

- no stripping of dorsal neck

- preserve deep deltoid for blood supply

- may require medial malleolar osteotomy

- in this case can curve incision up and around medial malleolus

 

Anterolateral

- allows assessment of reduction

- lateral screw prevents compression into varus and loss of medial length

- lateral to EDL, mobilise EDB

- > 7 cm skin bridge

- expose lateral talar neck

 

Reduce and ORIF

- only accept anatomical reduction

- avoid varus and shortening medial neck

- anteromedial and anterolateral K wires

- insert proximal to articular surface of head

- aim into posterior body

- parallel

- check II

- cannulated lag screws (titanium for future MRI)

- minifragment screws for osteochondral fragments

 

Talus ORIF APTalus ORIF LateralTalus ORIF

 

2.  Devitalised Type 3 / 4 with compound wound

 

Managment is controversial

 

1.  Reasonable to clean / replace / ORIF

- if become's infected remove 

- Abx spacer

- apply frame

- fuse late once infection cleared +/- lengthening

 

Compound Talus ORIF 1Compound Talus ORIF 2Compound Talus ORIF

 

Talus ORIF APTalus ORIF Lateral

 

2.  Can discard primarily & close wound

- fusion once soft tissues healed

- acute shortening and fusion with frame with proximal corticotomy and lengthening

Triple Arthodesis

Biomechanics

 

Able to achieve relatively high level of function after STJ fusion

- previously believed that isolated STJ fusion should not be performed

- believed that triple arthrodesis was operation of choice for hindfoot

- STJ fusion has superior result with less stress on AJ

 

Average loss of DF 30% / PF 10%

 

Position of hindfoot determines flexibility of transverse tarsal (CCJ & TNJ) joints

- imperative that fusion be positioned in ~ 5o valgus 

- permits TTJ mobility

- if varus TTJ locked & patient tends to walk on lateral aspect of foot 

 

Indications for STJ arthrodesis

 

 Subtalar Arthritis

 

Post traumatic / calcaneal fracture

 

RA

 

Primary OA

 

Coalition

 

Talar Coalition CN 1Calcaneonavicular coalition subtalar OA MRI

 

Tibialis posterior dysfunction

 

Neuromuscular disorders

- instability

- CMT / polio / nerve injury

 

Indication for Triple Arthrodesis

 

Valgus deformity

OA of CCJ / TNJ

 

Triple Arthrodesis

 

Technique STJ Fusion

 

Subtalar ArthrodesisSubtalar Arthrodesis 2

 

Approach

 

Position

- patient supine

- roll under hip to expose lateral aspect foot

- tourniquet, IV Abx, radiolucent table, II available

 

Incision 

 

Direct lateral approach -  Tip of fibula toward base of 4th MT 

- internervous plane between SPN and sural nerve

 

Superficial dissection

- peroneal tendons lifted dorsally

- elevate EBD

- fatty tissue over sinus tarsi

- expose STJ / CCJ / sinus tarsi

 

Deep dissection

- remove TC interosseous ligament

- clear out sinus tarsi

- diathermy artery of tarsal sinus

- insert lamina spreader to expose posterior facet

- need to expose medial facet medially

 

Debridement

- curette / osteotomes / burr

- simply remove cartilage if no deformity

- otherwise remove bone to correct deformity

- recreate 2 flat surfaces that come together in 5o valgus

- drill holes to stimulate bleeding +/- bone graft

- if previous calcaneal fracture, decompress lateral wall  

(5 - 10mm removed) 

 

Reduction technique in valgus foot

 

Deformity

- talus internally rotated on calcaneum

- navicular abducted on talus

 

Issues

- need T Achilles lengthening

(assess at end) 

- need to perform TNJ and CCJ fusion

- likely need to have open reduced TNJ / CCJ before STJ reduction

- may need lateral bone block

- often deficient skin laterally

 

STJ

- reducing calcaneum back under talus difficult

- calcaneum also abducted like navicular

- lamina spreader between lateral process talus and anterior aspect of calcaneum

- open it up

- calcaneum internally rotates / talus externally rotates

- screw like motion

- need to have all joints opened and exposed for this to occur

- need care to ensure don't place foot into varus

 

Fixation

 

Insert K wires for 6.5 mm/ 8.0 mm cannulated screw

 

- One or two from inferior calcaneum via stab incisions into body and neck of talus

 

Check position of K wires on II before screw insertion

 

Bone graft

- local usually sufficient 

http://www.boneandjoint.org.uk/content/jbjsbr/87-B/2/175.full.pdf

- if large correction take from proximal lateral or medial tibia  

 

TNJ fusion

 

Arthrodesis CCJ TNJ

 

Indications

- isolated TNJ OA (lose 80% subtalar joint motion)

- as part of triple arthrodesis

 

Midfoot Approach

 

Incision

- medial to T anterior, anterior to T posterior

- talar neck to naviculo-cuneiform joint

- protect saphenous nerve and vein

- Tibialis posterior guide to navicular

 

Exposure

- can sometimes only expose 2/3 of joint medially

- may need to utilize the lateral approach for full exposure

- inserting lamina spreader aids exposure to debride

- reduce forefoot onto navicular by adducting /plantar flexing and pronating it

- must not leave in varus

- provisionally fix with K wires

 

Fixation

- 2 x 4.0 mm cannulated screws

- from navicular into talus

- parallel or triangular 

- may need to make notch in medial cuneiform 

 

CCJ fusion

 

Incision

- exposed through continuation of lateral approach 

 

Fixation

- 2 x screws

- must hug lateral border

- alternatively can use specific plates

 

T Achilles lengthening

 

Indication

- tight T Achilles

- if don't will have to take a lot of bone to get foot plantigrade

 

Technique

A.  Formal Z lengthen

B.  Hoke lengthening

- want to lengthen laterally more than medially

- 2 incisions halfway laterally

- 1 half incision medially between them

- stretch out the T Achilles

 

Post-operative 

Back-slab for 2/52 

Wound inspection at 10 - 14/7

NWB in full cast for 4/52 

WBAT in walking cast for a further 6/52

6/52 radiologic assessment until union 

(pain-free WB with evidence radiologic union) 

Hip

AVN

Background

Bilateral Hip AVN Xray

 

Definition

 

Non-traumatic or traumatic condition of femoral head with bone death

 

Epidemiology

 

20 - 50 yo (average 38)

- M: F 4:1

 

NHx  

 

70-80% with AVN will progress within 1 year

 

Aetiology 

 

AS IT GRIPS 3Cs

 

Alcohol

- > 4000 ml / week

 

Steroids

- > 20mg / day

- often bilateral

 

Idiopathic

- incidence of hypercoagulability

- alcohol probably related to most idiopathic

 

Trauma 

- displaced subcapital

- dislocation

 

Gout, Gaucher's

Rheumatoid, radiation

Infection, increased lipids, inflamm (arteritis)

Pancreatitis, pregnancy

SLE, Sickle cell, smoking

CRF, chemotherapy, Caisson

 

Pathogenesis

 

Fat Embolism Theory

 

Alteration in lipid metabolism

- fat emboli have been demonstrated in subchondral arterioles in femoral head in patients on steroids

- steroids increases fat stores in liver, bm, blood

 

Lipocyte hypertrophy theory

 

Increased bone marrow fat stores & lipocyte hypertrophy 

- increased bone marrow pressure

- leads to decreased blood flow

- lipid lowering drugs shown to improve femoral head blood flow

- may represent a compartment syndrome

- Gaucher, leukaemia

 

Accumulative stress theory

 

Kenzora & Glimcher

- suggests AVN multifactorial

- accumulative insult

- eg alcohol, steroids, illness

 

Multiple hit theory

 

Either have cumulative dose response reaching threshold for AVN eg many different insults 

 

Susceptible individual exposed to aetiological factor

- attempts to explain why small ETOH or steroids causes AVN in some but not others

 

Vascular & Non Vascular Theories

 

1. Vascular 

 

A. Inside vessel

 

Fat Emboli in Alcohol & Steroids

Lipoproteins

?Nitrogen in Caisson Disease

Sickle Cell = Venous occlusion

Hyperlipidaemia of other causes

 

B. Vessel Wall

 

Traumatic disruption - 26 % of subcapital fractures

Vasculitis

Arteriopathy & haemorrhage

 

C. Outside vessel via intraosseous pressure

 

Fat cell hypertrophy 

- steroids / alcohol 

- "Starling" effect

- increased intraosseous hypertension in fixed space

 

Oedematous marrow

- Gaucher cells / leukaemia / DXRT / gout / CRF

 

2.   Non Vascular

 

Chemotherapy / Radiotherapy  

- osteocyte death

 

Steroids

 

Cumulative Risk

- dose x time cortisol ? 2000mg

 

Idiosyncratic

- incidence 3-25%

- onset ~ 6/12 - 3 years

- usually bilateral & multiple sites

 

Mechanism

- steroids cause osteoblastic stem cells to become fat cells 

 

Alcohol 

- MOA uncertain

- ? 2° to both intraosseous HTN & altered fat metabolism with fat emboli

- often affects other sites

 

Caisson Disease

- 2° N2 in blood vessels & extravascular

- compressed air workers ~ 20%

- divers ~ 5% in army

- humeral head > femoral

 

Pathology

 

Starts in Anterior / Superior / Lateral head 

- wedge shaped area

 

Cysts

- regions of bone reabsorption

- fibrous regions on microscopy

 

Crescent Sign 

- subchondral collapse of the necrotic segment

- separation of subchondral plate from necrotic cancellous bone

 

Collapse

- accumulated stress fracture

- 2° OA results

- NHx is progression to collapse in >90%

 

Dead bone is resorbed prior to new bone formation  

- resorption begins just after vascular invasion

- resorption continues until majority of necrotic haversian bone is removed, but almost none of interlamellar bone removed

- only once this has occurred do osteoblasts begin forming new haversian bone

 

It is at the revascularisation phase when the head is at its most susceptible

 

Stages

 

1. Necrosis

 

2. Inflammation / Revascularisation / Resorption

 

3. Repair - osteoblasts, new bone on dead trabeculae 

 

4. Remodelling

 

Four Causes Sclerosis

 

1.  Relative osteopenia in surrounding bone

2.  Marrow saponification

3.  Microfracture

4.  New bone apposition

 

Classification Ficat 1985

 

Stage 0 

 

"Silent contralateral hip" 

- preclinical - non painful

- X-ray normal

- MRI = double Line positive on T2

- cold scan

 

Stage I 

 

Clinically painful

- normal X-ray 

- increased uptake on scan

- MRI positive

 

Hip AVN MRI Anterior headHip AVN MRI T1

 

Stage II

 

Diffuse porosis with

- sclerosis 

- cystic areas of reabsorption

 

HipAVN Type 2Hip AVN Type 2 APHip AVN Type 2 Lateral

 

Transition

- Crescenteric sign / subchondral fracture

 

Stage III

 

Collapse / Flattening

- sequestrum

- preserved joint space

- typically anterolateral head

 

Hip AVN Type 3

 

Stage IV

 

OA superimposed on a deformed head

 

Hip AVN Type IIIHip AVN Type 3Hip AVN Type IV

 

Steinberg 

 

1.  Divided extent of head involved

- most important prognosticator

 

A = Mild <15%

B = Moderate 15-30% 

C = Severe >30%

 

2.  Stages

 

Stage 1: normal xray

Stage 2: sclerosis

Stage 3: crescent sign / subchondral collapse

Stage 4: flattening of femoral head

Stage 5 & 6: OA

 

Kerboul Combined Necrotic Angle 

 

JBJS B 1974

 

Guide to outcome 

- AP + Lat Necrotic Wedge Angle 

- > 200° = Poor

 

CT

 

Limited place

- can eiagnose early collapse & flattening

- 1/3 of Grade II upgraded to grade III by CT

 

Hip AVN CT

 

Te Scan

 

Sensitivity 80%

- non-specific

- most useful to investigate if head vascular after subcapital fracture

 

MRI

 

Sensitivity 100% in one series

- may take up to 7 days to show 

 

Low T1 / High T2

 

T2 Double Line Sign

 

Hip AVN MRI T2 Double Line Sign

 

Two lines virtually diagnostic of AVN

- outer line / low signal intensity

- inner line / hihg signal intensity / hypervascular granulation tissue

 

DDx Transient osteoporosis of the Hip

 

Incidence

- third trimester pregnancy

 

MRI

- oedema into metaphysis or neck

- suspect AVN if collapse 

 

Natural History AVN

 

Asymptomatic Hip

 

Mont et al JBJS Am 2010

- systemic review of asymptomatic hips

- 59% progressed to symptoms or collapse

- small medial lesions progressed to collapse < 10%

- sickle cell high risk, SLE low risk

 

Hernigou JBJS Am 2006

- 91% asymptomatic sickle cell AVN became symptomatic

- 77% collapse

Management

Management Summary

 

Stage 0

 

Natural history mixed

- depends on size of lesion and diagnosis

- treat if becomes asymptomatic

- may benefit from bisphosphonates

 

Stage 1 / Normal X-ray, abnormal MRI

 

Forage: 80% G/E

Bisphosphonates

 

Stage 2 / Abnormal X-ray with cysts and sclerosis

 

A:  As for Stage I

 

B:  Vascularized fibula graft: 80% 

 

Stage 3 / Collapse / Crescent sign

 

A:  Forage: 20% G/E

 

B:  Osteotomy:  80% G/E (CAN < 200o)

 

C:  Trapdoor and BG 80%

 

D:  Vascularised fibula graft: 80% G/E

 

E:  Limited Femoral Head Resurfacing

 

Stage 4

 

A:  Conventional THR

 

B:  Resurfacing 

 

C:  Arthrodesis 

- only if unilateral (<50%)

 

Non operative Management

 

Options

 

Bisphosphonates

ECSW

Hyperbaric oxygen

 

Bisphosphonates

 

Mechanism

- inhibit osteoclast absorption

- limit head collapse

 

Results

 

Lai et al JBJS Am 2005

- RCT of aledronate v control in non traumatic AVN

- 2/29 in treatment group collapsed, 1 had THR

- 19/25 in control group collapsed, 16 had THR

 

ECSW

 

Extracorporeal shock wave therapy

 

Results

 

Wang et al JBJS Am 2005

- RCT of ECSW v forage & bone graft

- 80% improvement and 10% unchanged in ECSW

- 29% improved and 36% unchanged in surgical group

 

Hyperbaric Oxygen

 

Results

 

Camporesi J Arthroplasty 2010

- RCT of stage II AVN treated with hyperbaric O2 or air

- all HBO patients were pain free and non required THR

- 7/9 HBO showed radiographic healing

 

Operative Management

 

Options

 

Femoral head preserving / pre-collapse

- forage

- vascularised bone graft

- non vascularised bone graft

 

Salvage / post collapse

- osteotomy

- limited resurfacing / femoral resurfacing

- THR

 

Femoral Head Preserving

 

Forage / Core Decompression

 

Concept

 

Ficat / Arlet

- initially used for diagnosis of HTN

- then used as treatment

- noticed pain relief of & cessation of progress

 

Theory

- decompress intraosseous hypertension

- promotion of vascular ingrowth

- promotion creeping substitution

 

Issues

 

Provides good pain relief

Does it prevent collapse / alter NHx?

Related to stage and size of lesion

 

Technique

 

Hip Forage Intraoperative

 

Take 6-8 mm core 

- insert guide wire under II

- ensure entry above LT

- 5mm from subchondral bone

- use DHS triple reamer

- NWB 6/52

 

Results Pain Relief

 

Stulberg Clin Orthop 1991

- prospective randomised study

- forage vs nonoperative management

- forage 70% success Ficat stage I to III in Harris Hip scores

- nonoperative success 20% Stage I / 0% Stage II / 10% stage III

 

Results NHx

 

Steinberg J Arthroplasty 1998

- patients post core decompression

- < 15% head involvement stage IA & IIA / only 20% needed THR

- > 15% head involvement stage IB & IIB / 40% needed THR

 

Khoo et al JBJS Br 1995

- RCT non operative v core decompression

- excellent pain relief in decompression group

- 80% developed femoral head collapse in both groups

 

Vascularised Cortical Bone Grafts

 

Concepts

- core decompression and removal necrotic bone

- support of subchondral bone with vascularised fibular graft

- revascularisation

- callous formation / osteoinduction

 

Technique

- approach between TFL and G med

- reamer inserted

- packed with cancellous bone

- fibula segment harvested with peroneal artery and vein

- stabilised with K wire

- anastomosed to LCF

- abutting subchondral bone

 

Results

 

Scully et al JBJS Am 1998

- stage III 

- 81% 4 year survival vascularised fibula graft

- 21% 4 year survival core decompression

 

Berend et al JBJS Am 2003

- stage III disease

- failure with THR as end point

- 64.5% 5 year survival

 

Non vascularised bone graft 

 

Technique

 

1.  Cortical strut graft

 

2.  Lightbulb procedure

- head neck junction

- cancellous bone graft

 

3.  Cartilage trapdoor 

- evacuate necrotic bone

- pack with cancellous bone

 

Results

 

Wang Int Orthop 2010

- trapdoor technique

- excellent or good results in 90 - 100% stage IIA or IIB

 

Salvage

 

Osteotomy

 

Theory

 

Aim is to prevent collapse 

- move the avascular segment away from weightbearing area 

- also decompress intraosseous HTN

- must have sufficient intact femoral head to weight bear upon

 

Indications

 

Stage III 

CNA <200°

Young patient 

Not on steroids

 

Contra-indications

 

Stage III with total head involvement

Stage IV

Steroids

 

Technique

 

CT / MRI  / XR to decide osteotomy direction

 

Usually

- anterolateral AVN 

- undergoes a valgus flexion intertrochanteric osteotomy

 

Results

 

Ha et al JBJS Am 2011

- 113 hips followed up for 4 years

- secondary collapse in 24%, THR required in 12%

- age > 40, stage III, CNA > 2000 and BMI > 24 poor prognostic factors

 

Limited Resurfacing Arthroplasty

 

Concept

 

Restores spericity to femoral head

- limits FAI which may cause progression to OA

- need to have limited acetabular damage at time of surgery

 

Results

 

Mont et al J Arthroplasty 2001

- 30 patients treated after intra-operative inspection acetabulum

- all stage III or IV

- 90% 7 year survival

 

Hemiresurfacing

 

Concept

 

Femoral resurfacing only

- again need good acetabular cartilage

- not as predictable pain relief

 

Results

 

Hungerford et al JBJS Am 1998

- 30 patients stage III or IV

- 61% G/E at 10 years

- remainder needed conversion to THR

- suggested good intermediate option in young patient

 

THR

 

Issues

 

? Failure rate higher than in age matched OA patients

- also worse if caused by ethanol / steroids

 

Results

 

Ortiguera et al J Arthroplasty 1999

- age matched AVN and OA

- 178 patients in each group

- follow up 17 years

- no difference patients over 50

- < 50 significant increased risk aseptic loosening

 

Australian Joint Registry 

- 7 years

- THR Revision rate 5% (4% OA)

- resurfacing 6% (4% OA)

 

 

Acetabular Fractures

Background

Anatomy

 

Unusual anatomic convergence of ilium, pubis and ischium

- covered entirely by hyaline cartilage

- except at acetabular fossa, which is the site of attachment of the ligamentum teres

- deepened by peripheral fibrocartilage labrum

 

2 column theory (Letournel and Judet)

 

Anterior Column 

- superior pubic ramus

- anterior acetabular wall, anterior dome

- anterior iliac spines and anterior ilium

 

Acetabulum Anterior ColumnPelvis Anterior Column

 

Posterior Column 

- ischium

- posterior acetabular wall, posterior dome

- posterior ilium

 

Acetabulum Posterior ColumnCT Pelvis Posterior Column

 

Quadrangular Plate

 

CT Quadrangular Plate

 

Mechanism

 

Axial load applied through femur

- type of fracture depends on position of femur at time of injury

- IR - posterior column

- ER - anterior column

 

Examination

 

Resuscitation EMST

 

Detailed neurological exam

- sciatic nerve damaged in 20% cases with posterior wall or column injury 

- usually peroneal division

 

Careful soft tissue evaluation

- closed degloving injury

- 'Morel-Lavallee' lesion

- the serosanginous fluid collection can be culture positive in up to 30%

 

X-ray / 5 standard views

 

AP / Six X-ray Landmarks

 

Acetabulum Anterior and Posterior WallsAcetabulum Ilioischial Iliopectineal LinesAcetabulum Roof and Teardrop

 

1.  Iliopectineal line 

- along pelvic brim to pubic symphysis

- anterior column

 

2.  Ilioischial Line 

- pelvic brim to ischial tuberosity

- posterior column

- formed by posterior 4/5 of quadrilateral surface ilium

 

3.  The Teardrop 

- lateral: subchondral bone condensation at anterior margin of cotyloid fossa 

- medial:  anterior flat part of quadrilateral surface of iliac bone

 

4.  Roof of acetabulum

 

5.  Anterior rim of acetabulum

- semilunar

 

6.  Post rim of acetabulum

 

Judet views  / 45o obliques

 

Internal Oblique / Obturator Oblique

- affected side rotated forward

- anterior column + posterior wall

 

Judet ViewJudet View Acetabular FractureAcetabular Fracture Judet View

 

External Oblique / Iliac Oblique

- unaffected side rotated forward

- posterior column + anterior wall

 

Inlet view / Outlet view

 

Indicated for pelvic fractures usually

 

Pelvic Fracture Inlet ViewPelvic Fracture Outlet View

 

CT

 

Configuration

 

1-2 mm sections

 

CT reconstruction

- remove head to view acetabulum

- beware volume averaging

- used to guide surgery

 

Acetabular Fracture CT Reconstruction

 

Diagnose

 

Loose bodies

Femoral head fractures

Subtle subluxation

Articular steps

Roof arc measurement

 

Letournel Classification

 

5 Elementary

5 Complex

 

Elementary / One primary fracture line

 

1.  Posterior Wall

- often associated with posterior dislocation

- may be in one or many pieces

- may have marginal impaction fracture

 

Acetabular Fracture Posterior WallAcetabulum Posterior Wall Fracture

 

2.  Posterior Column

- whole posterior column separated in one piece

- fracture greater sciatic notch

- through inferior acetabulum

- into obturator foramen

- through inferior pubic rami

 

Posterior Column Fracture 1Posterior Column Fracture Xray 2Posterior Column Fracture Xray 3

 

Acetabular Fracture Posterior ColumnAcetabular Fracture Posterior Column 2

 

3.  Anterior Wall

 

Acetabular Fracture Anterior Wall

 

4.  Anterior Column

- from ilium above ASIS

- through inferior acetabulum  

- across obturator foramen

- out through inferior rami

 

Acetabular Fracture Anterior WallAcetabular Fracture Anterior Column

 

5.  Transverse

- from greater sciatic notch to AIIS

- obturator foramen not fractured

 

Pelvic Fracture TransverseAcetabular Fracture Transverse CT1Acetabular Fracture Transverse

 

High - above acetabulum 

Low - through acetabulum

 

Complex / More than one primary fracture line

 

1.  Posterior column & posterior wall

 

2.  Transverse & posterior wall

 

3.  T-shaped

- transverse through acetabulum

- inferior fracture line to obturator foramen

 

4.  Anterior & posterior hemi-transverse

 

5.  Both column

- Y Shaped transverse above acetabulum

 

Acetabular Fracture Both Columns 1Acetabular Fracture 2 Column

 

Acetabular Fracture 3D CT Anterior ColumnAcetabular Fracture 3D CT Posterior Column

 

Determinants of outcome

 

1.  Fracture displacement

- < 2mm articular step

 

Acetabular Fracture DisplacedAcetabular Fracture Undisplaced

 

2.  Fracture location

 

Early onset of arthritis and poor clinical results correlate with 

- displacement present at the time of union within the weight bearing dome

- any roof arc measurement less than 45°

- a broken CT subchondral ring

 

A.  Matta roof arc measurements

 

Describe location of fracture lines in relation to roof of acetabulum

- integrity of acetabular roof

- must be no hip subluxation

 

3 roof arc measurements

- AP, 2 Judet's views

- vertical line to centre of head

- line to where fracture enters joint

- the larger the arc, the further the fracture from the roof

- 10o - fracture in roof

- 900 - low fracture

 

Weight bearing dome is intact if angle > 45o on all 3 views

 

B.  CT subchondral arc

- 10 mm below subchondral bone of roof

- similar to xray roof arc measurements

 

Acetabular Fractures CT Subchondral arc 1Acetabular Fracture CT Subchondral Arc 2

 

3.  Stability / Concentric reduction

 

Subluxation

- incongruency between the head and the roof

- poor clinical results are obtained in more than 50% of fractures in which the head is subluxed  

- may also have an element of dynamic instability, with certain posterior wall fractures

 

Acetabular Fractur Non concentric 1Acetabular Fracture Non Concentric 2

 

Any subluxation on CT demonstrates clinical instability

- fractures affecting 40% or more of the posterior wall are usually associated with instability

- fractures less than 40% should be screened for stability under II

 

4.  Other factors

 

Direct cartilage injury at time of impact

Neurological injury

AVN of head

Management

Acute management

 

Resuscitation

 

EMST

Neurovascular assessment

Investigations - exclude Pipkin, NOF

Emergent reduction / skeletal stabilisation

Assess stability

Re-evaluate sciatic nerve

 

Insertion Femoral Steinman Pin

 

Indications

- displaced acetabular fracture

 

Femoral Steinman Pin APFemoral Steinman Pin Lateral

 

Technique

- above blummenstaat's line

- in metaphyseal bone

- minimum 10 pounds weight, may need more

- assess post operative reduction

 

Acetabular Fracture Pre Steinman PinAcetabular Fracture Post Steinman Pin

 

Goals of Management

 

1.  Restore Articular Congruency

2.  Reduce & Maintain Hip in Acetabulum

 

Non operative Management

 

Radiographic factors

 

1.  Articular step < 2mm

2.  Weight bearing roof intact

- Matta Roof > 45o

- CT subchondral roof 10 mm

3.  Congruent reduction

4.  Stable < 40% posterior wall fracture

 

Results

 

Tornetta JBJS Br 1999

- 38 hips with above criteria for 2.7 years

- good or excellent outcome in 91%

- poor outcome related to other injuries

 

Patient factors

 

Elderly

Osteoporotic bone

Pre-existing arthritis

 

The elderly patient can have a THR as salvage if required down the track

 

Operative Management

 

Indications

 

1.  Incongruent reduction

2.  Non intact weight bearing dome

3.  Articular step > 2mm 

4.  Retained fragment

5.  > 40% posterior wall or instability

 

Surgical factors

 

1.  Surgeon experience

- steep learning curve

 

Letournel & Judet Fractures of the Acetabulum 1993

- initial rate non anatomical reduction 32%

- 4 years later 10%

 

2.  Surgical timing

 

Letournel & Judet

- anatomical reduction in only 50% operated after 21 days

- if operate too early, bleeding +++

 

3.  Fracture complexity

 

Matta  JBJS Am 1996

- 262 patients

- 96% elemental fractures anatomically reduced

- 64% complex

 

ORIF 

 

Aim

 

1.  Anatomic reduction

2.  Provisional fixation with lag screws 

3.  Buttressing with curved reconstruction plates 

 

Options

 

1.  Posterior / Kocher-Langenbeck approach

- posterior column / wall

 

2.  Ilioinguinal approach

- anterior column / wall

 

3.  Extended iliofemoral approach

- Smith-Petersen extended over iliac crest

- for transverse / both column fractures

 

4.  Triradiate approach

- Kocher-Langenbeck with anterior extension from GT to ASIS

- wide exposure for both column fractures

- high incidence HO

 

Triradiate approach Both Column Fracture

 

Preferred option is to perform

- ilioinguinal for anterior column / wall

- posterior / Kocher Langenbeck for posterior column / wall

- do both 1 week apart for combined fractures

 

Techniques

 

Posterior Column & Wall Fracture

 

Acetabulum Posterior Wall Plating 1Acetabulum Posterior Wall Plating 2Acetabulum Posterior Wall Plating 3

 

Position

- IDC, radiolucent table, IV Abx

- lateral position but patient rolled excessively over

- patient 45o up from table, exposes posterior

- top leg hip flexed, knee flexed

- bottom leg extended

- blankets under top leg

- lateral support in front of top knee to prevent too much hip flexion

- prevents excessive tension on sciatic nerve

 

Standard posterior approach

- divide fascia lata

- find and protect sciatic nerve at all times

- do so by keeping hip extended and knee flexed

- expose short external rotators, divide 1cm from insertion to preserve blood supply

- usually must divide some of G. max

- elevate G medius from ilium

- steinmann pin in ilium for exposure

- expose ischial tuberosity by elevating biceps femoris, again protecting sciatic nerve at all time

- steinmann pin in ischium

 

Reduction can be aided but applying femoral distracter

- between ilial and ischial pins

 

Expose fracture

- posterior wall fracture, elevate and clean callous

- capsule usually partially avulsed

- ensure no femoral head fractures or loose fragments

- posterior column fracture often up in ilium, can put a plate across it

 

Reduction

- often indirect

- buttress plate from Ischial Tuberosity to Ilium

- contour or use pre-contoured

- screws at plate extremities

- often 2 parallel plates if wall and column fracture

 

II to ensure screws not in acetabulum

 

Anterior Column & Wall Fracture

 

Acetabulum ORIF 2 Column APAcetabulum ORIF 2 Column Judet 1Acetabular ORIF 2 Column Judet 2

  

Position

- radiolucent table

- IDC to decompress bladder

- IV Abx

- sandbag under operative side for some elevation

- need to prep and drape pelvis so can virtually access both ASIS 

- often need to get  across pubis

 

Ilioinguinal approach

 

Curvilinear incision from above pubis to ASIS

- identify and protect LFCN / below ASIS

- divide external oblique 1 cm above inguinal ligament

- identify and protect spermatic cord / round ligament

- divide posterior wall / internal oblique and transversus

 

3 windows (medial / middle / lateral)

- find external iliac artery and vein with peanuts / place sling

- find psoas and femoral nerve / place sling

- find iliopectineal fascia between vessels and psoas and divide with scissors

 

Medial window medial to vessels

- superior pubic rami

- may have to release some of rectus

 

Beware corona mortis

- anomolous vascular connection

- 10 - 15% patients

- between external iliac / epigastric artery

- to obturator artery

 

Middle window between psoas and vessels

- exposes quadrilateral plate

 

Lateral window lateral to psoas

- elevate iliacus off crest to expose fracture in iliac wing

- exposes around to SIJ

 

ORIF

 

1.  Reduce quadrilateral plate

- small T plate / will sit under pelvic reconstruction plate

- separate recon plate

 

ORIF Quadrilateral Plate

 

2.  Plate iliac crest fracture

- long 13 hole plate from pubis

- along superior pubic ramus up onto inner table of ilium

- indirect acetabular reduction

 

Results

 

Judet and Letournel 1980 417 Fractures

- 73% perfect reduction with 84% very good results

- imperfect reduction 55% good results

- infection 5.6% / heterotopic bone 18%

- poor results related to > 3 weeks

 

Matta 1996 258 Fractures

- anatomical reduction 71% with 76% excellent to good results

- poor results related to injuries to femoral head / age / post-operative complications

- AVN 3%

 

Complications

 

Heterotopic Ossification

- ilioinguinal 1%

- Kocher-Langenbeck 7%

- extended Iliofemoral 12%

 

Failure of fixation

 

Acetabular Fracture Failed ORIF 1Acetabular Fracture Failed ORIF 2

 

Very problematic

- often need revision to THR

- pelvic discontinuity must be addressed

 

Acetabular Fracture Failed ORIF CT 1Acetabular Fracture Failed ORIF CT 2THR Post Acetabular Fracture

 

DVT 

- rate very high

- prevent with mechanical and chemical prophylaxis

 

Sciatic nerve injury 2% 

- especially with posterior approach

 

AVN 2%

- higher with posterior dislocations and Pipkin fractures

 

Infections 

- occur in 2-5%

- increased in the presence of Morel-Lavallee lesion

 

Arthritis

- the most common complication

- anatomic reduction - 10%, usually after 10 years

- imperfect reduction - 45%, usually before 10 years 2,6

 

Hip OA post Acetabular FractureHip OA post Acetabular Fracture

 

Bladder and spermatic cord injury

 

Hernia formation

 

Vascular injury

 

External iliac vein

- control distally with vessiloop

- suture with 5.0 / 6.0 prolene on noncutting needle

 

 

 

 

 

Arthrodesis

IndicationsHip Fusion

 

Young adult 

- 16 - 30 years old

- monoarticular disease

- heavy demand 

 

Exhausted options of osteotomy

- risk of THA failure  / multiple revision surgeries considered too high

 

Aims of arthrodesis

 

Maximise bony contact

Minimise shortening

Provide rigid internal fixation

Compress the fusion site

Facilitate future conversion to THR

 

Contraindications

 

AVN

- difficulties in obtaining arthrodesis without femoral bone stock

 

Poor bone stock due other causes

 

Bilateral hip disease

- need ROM in other hip 90o

- in order to compensate in gait

 

Polyarticular disease eg Rheumatoid arthritis

- likely to develop hip / knee / back OA

 

Degenerative disc disease

- lumbar spine ROM important to compensate in gait and ability to sit in chair

 

Stiff ipsilateral knee or contralateral hip 

 

Advantages

 

Good pain relief

 

No activity restriction

- most patients employed

- can return to normal jobs, even heavy labour

- most able to walk > 1 mile

 

Long term solution c.f. THA

 

Disadvantages

 

Functionally inferior to THA

 

Increased stress on other joints

 

1.  Lumbar spine 

- 50% back pain

- most common reason for converting to THR

 

2.  Ipsilateral knee 

- 50% knee pain and instability

- increase rotation demanded in knee due to arthrodesis

 

3.  Contralateral hip

- has to compensate with increased ROM

- may predispose to OA

- will certainly worsen any underlying arthritis

 

Difficulties with certain activities

 

Squatting

Supine sex

Running

Sitting erect in chair

Difficulty putting on shoes

 

Gait abnormalities

 

Increased energy requirements

- increased oxygen consumption

- gait 50% less efficient

 

Increased lumbar lordosis to compensate 

- decreases stride length

- shortened stance phase

- contralateral hip has increased mobility compared to normal

 

Surgery

 

Concepts

 

To retain option of conversion to THR 

- don't use pelvic osteotomy

- preserve abductors

 

Types

 

1.  Intra-articular

- most common

- allows disease to be addressed

- better correction of deformity

- difficult in paediatrics due to large amount of cartilage present

 

2.  Extra-articular

 

3.  Combined

- usually use combination 

 

Position

 

Sagittal / 25° flexion

- <20° flexion - difficult to sit

- >25° flexion - difficult to walk due to LLD

 

Coronal / 5° adduction

- never abduction: can't walk, fall over even with 5° abduction

- too much adduction: LLD

 

Rotation / 15° ER 

 

< 2 cm LLD

 

Complications

 

Pseudarthrosis - 10% 

Mal-positioning

 

Methods to Increase Union

 

1.  Inter-trochanteric / subtrochanteric osteotomy 

- can increase union rate by decreasing lever arm of abductors

- come back 6/52 later and fix intertrochanteric fracture

 

2.  Vascularised bony extra-articular method

- iliac crest with Tensor Fascia Lata still attached

- the graft is inserted into trough in the anterior joint

 

Options

 

1.  Lateral cobra plate

- detach GT

- pelvis to femur

- nil pelvis osteotomy

 

Hip Fusion Cobra Plate

 

2.  DHS

- Sunderland method

 

Hip Fusion APHip Fusion Lateral 2

 

3.  Anterior plating

- Smith Peterson approach

 

4.  Double plating

- anterior and lateral plate

 

Sunderland Method

 

Intra-articular approach /  2 hole DHS

 

Technique

 

Radiolucent table with II

- supine

 

Smith Peterson approach

- leave abductors intact

- dislocate hip anteriorly

- between sartorius and TFL

- between G medius and Rectus Femoris

- take off reflected head

 

Remove cartilage from head & acetabulum

- cup arthroplasty instruments useful

- approximate raw surfaces

- pack cancellous autograft

- position hip & hold with guide-wires temporarily

- place one guide wire central in head

 

Check position of hip

- need to be able to do intra-operative Thomas test

- FFD 25o / Add 5o / ER 15o

 

Fix with 150° DHS

- through joint into thick supra-acetabular area of ilium

- supplement with additional screws as necessary

- +/- Sub-Trochanteric Osteotomy

 

Spica at 2/52 for final position 

- NWB until xray union union

 

Schneider Technique 

 

Previously very popular technique

- don't use now as THR conversion not possible 

 

Characterised by pelvic osteotomy

- increases surface area for fusion

- pelvic osteotomy compromises future THR conversion

 

Femoral head compressed into osteotomised pelvis

- Lateral Cobra plate fixed to pelvis

 

Kostuik

 

Lack of head technique

- for post AVN or failed THR

- using a lateral Cobra plate & inserting the neck into the acetabulum

 

Lateral approach with GT osteotomy

- reflect abductors cephalad

- denude acetabular cartilage

- apply lateral cobra plate

- fix the GT to the arthrodesis with screws and place graft at the site

- +/- anterior plate

 

Britian Technique 

 

Extra-articular arthrodesis

- ischio-femoral arthrodesis

- oblique subtrochanteric osteotomy

- place tibial cortical graft from inferior femur to osteotomy in ischium

- medialize femur on graft

- spica

 

Results of Arthrodesis

 

Sponseller JBJS 1984 (classic report)

 

53 patients at 20 years post fusion

- average age 14 years

- back pain 60% / similar incidence back pain to general POP

- ipsilateral knee pain 40%

- contralateral hip 20%

- pain was unrelated to length of arthrodesis

- high functional abilities / played sport

- knee laxity of MCL was common 2° to hip excesssive adduction in fusion

- 15% conversion to THR (for back or knee pain)

 

TKR with fused Hip

 

Technically difficult

- have knee over edge of bed

- only way to get high flexion of knee for insertion tibial prosthesis

 

Poor results

- poor ROM

 

Best to revise arthrodesis first

- not if abductors not functioning

 

Conversion to THR

 

Indication 

- back pain main indication

- ipsilateral knee pain

- contralateral hip pain 

 

Issues

 

1. Abductors 

- adequate function related to good outcome

- test by palpation preoperatively

 

2. Reason for fusion ?infection

 

3. Bony loss at acetabulum & femur

 

4. LLD

- average 2cm

 

5. Skin

 

6.  Higher failure than 1° THR

 

Results

 

Good relief of LBP

- less so hip and knee

- most patients happy

- hip scores change little (owing to good results from arthrodesis)

 

LL equality achieved

 

Improved ROM

 

Gait poor for a couple of years

- related to abductor function

- intensive physio required

 

Survival

- 80% 10 year

- increased risk of infection

 

Arthroscopy

Indications

 

Removal of loose / foreign bodies

 

Hip Scope Loose BodyHip Scope Loose Body RetrievalHip Loose Body

 

Synovial biopsy / subtotal synovectomy / synovial chondromatosis

Management of labral tears / CAM Lesions

Osteochondritis dissecans / chondral lesions

Treatment of pyarthrosis

 

Position

 

Supine 

Lateral decubitus

II and traction

 

Hip Arthroscopy Set up

 

Distraction

 

Forces

- both longitudinal & lateral in direction with vector parallel to femoral neck

- force required to distract femoral head varies considerably 

- range from 25 lb to 200 lb in unanesthetised adult volunteers

- majority performed with 50 lb (225 N) or less 

- important to limit periods of distraction with higher forces

 

Aids

1.  GA & skeletal muscle relaxation

2.  Negative intra-articular pressure

- released via joint capsule puncture with spinal needle + saline

- reduces force for distraction by 1/2

- "vacuum effect"

 

Portals

 

Anterolateral

- viewing portal

 

Anterior

- working portal

 

Posterolateral

- working portal

 

Portal Placement

 

Hip Arthroscopy DistractionHip Arthroscopy InsufflationHip Arthroscopy Trochar InsertionHip Arthroscopy Cannular

 

Anterolateral portal / viewing portal

 

Anterolateral Portal 1Anterolateral Portal 2Anterolateral Portal 3

 

Insertion point

- 2 cm anterior to GT

- superior aspect of GT

 

Inserted under fluoroscopic guidance

- spinal needle directed medially & superiorly at 45° in each plane

- aim towards sourcil but under labrum

- joint distraction increases space in joint

- joint distended with normal saline

- guide wire inserted / blunt trochar / cannula

 

Dangers

- LFCN - may result in partial or complete neuropraxia

 

Hip Arthroscopy Anterolateral InstrumentationHip Scope Air Arthrogram

 

Anterior portal / working portal

 

Anterior Portal 1Anterior Portal 2Hip Scope Nerves at Risk

 

Intersection of perpendicular lines

- superior aspect of GT and inferiorly from ASIS

 

Inserted under direct vision

- guide wire / trochar / cannula

 

Dangers

- femoral NV bundle is 3 to 4 cm medial to insertion site 

- if placed inferior to neck ascending branch of lateral femoral circumflex artery is at risk

 

Hip Scope Anterior PortalHip Scope Anterior Portal 1Hip Scope Anterior Portal 2

 

Posterolateral Portal

 

Insertion point

- 2 cm posterior to GT

- level with superior border GT

 

Uses

- insert drainage portal

- improves visualisation

 

Danger

- sciatic nerve especially if foot ER during insertion

 

Posterior PortalHip Scope Nerves at Risk 2

 

Examination

 

Central compartment

- femoral head in acetabulum

- examine chondral surfaces

- examine labrum / debride / repair

 

Hip Arthroscopy Central Compartment

 

Peripheral

- head neck junction

- hip flexed, traction removed

- capsulotomy often required

- removal of CAM lesions

 

Hip Arthroscopy Peripheral Compartment

 

Complications

 

Nerves

 

LFCN - anterolateral portal

Pudendal - traction

Sciatic - from traction / posterolateral portal

 

Pressure necrosis

 

Foot, scrotum, or perineum 

 

Cartilage

 

Scuffing of articular surfaces 

 

Infection

 

Rare 

 

 

Femoral Head Fractures

Incidence

 

5-15% of posterior dislocations

 

Aetiology

 

Posterior hip dislocation

 

Pipkin Classification

 

Type I - head fracture below fovea

 

Undisplaced

- non operative

 

Displaced

- excise fragment if small

- ORIF fragment if large (can contribute to instability)

 

Pipkin Fracture Type 1

 

Type II - head fracture above fovea

 

Undisplaced

- rare, usually unstable

 

Displaced

- excise if small

- ORIF if large

 

Type III - Type I/II with NOF fracture

 

Issue

- very high incidence of AVN

 

Mangement

- ORIF young patient

- hemiarthroplasty / THR older patient

 

Pipkin Fracture Type 3

 

Type IV - Type I/II/III associated with acetabular fracture

 

Pipkin 4 Fracture

 

Non operative management

 

Indications

 

Type 1

- < 2mm displacement

- stable hip

- congruent joint

 

Type 2

- rarely anatomic

- usually unstable

 

Surgical Management

 

Choice of Approach

 

Fragment usually anteromedial

 

Type 1 and II

- anterior or anterolateral approach

- Smith Petersen / Watson Jones

- careful capsulotomy to preserve blood supply

- deep branch MCFA runs along superior femoral neck

 

Pipkin Open 1Pipkin Open 2Pipkin Open 3Pipkin ORIF

 

Type III

- anterolateral approach / Watson Jones

- ORIF NOF + fix/excise Pipkin fracture in young patient

- very high incidence AVN

- THR > 60

 

Type IV

 

A.  Associated with posterior dislocation / non operative acetabular fracture

 

Posterior approach

- this can make it difficult to access fragment

- need IR +++

- can attempt posterior to anterior screw fixation

 

Anterior approach

- if stable and no acetabular fracture requring ORIF

- involves making anterior capsulotomy

- patient already has posterior capsular defect

 

B.  Associated with posterior acetabular wall fracture that needs ORIF (>40%)

- posterior approach

 

C.  Associated with anterior acetabular fracture

- ilioinguinal with SP extension

 

Anterior Approaches

 

Many options

- Hardinge

- Watson Jones

- Smith Peterson 

- Ganz osteotomy

 

Any of these are blood supply preserving if perform safe capsulotomy

- avoid capsulotomy along superior neck

- Z capsulotomy

- capsulotomy along anterior acetabular rim superior to inferior

- along inferior femoral neck

- down medial femur

 

Ganz trochanteric flip osteotomy

- trochanteric slide

- gluteus medius and sastus lateralis attached / digastric

- osteotomy with saw posterior to anterior

- leave short external rotators attached to preserve deep branch MCFA

- slide GT fragment anteriorly

- capsulotomy as above

- allows access to anterior aspect femoral head

- dislocate femoral head anteriorly / surgical dislocation

 

Smith-Petersen approach

- good approach if only Pipkin fracture needs fixation

- higher risk of HO

 

Complications

 

Sciatic nerve injury 4%

- traumatic

- iatrogenic

 

Infection 3%

 

Recurrent instability

- large femoral head fracture excised

- posterior wall fracture

- rarely due to labral tear

 

AVN

 

HO

- increased with anterior approach

 

OA

 

Results

 

Giannoudis et al Injury 2009

- systematic review

- Pipkin I: excision gave better results than fixation

- Pipkin II: ORIF
- AVN 11% / OA 20% / HO 17%

- no difference between trochanteric flip / anterior or posterior approach

 

Chen et al Int Orthop 2010

- RCT of excision v non operative for Pipkin 1 in fracture dislocation

- better outcomes in excision

 

Femoral Osteotomy

Background

Indications

 

OA

Prevention OA i.e SUFE / Perthes / DDH

Deformity

Non union

Coxa Vara

 

OA

 

Rationale

 

Most OA is secondary to pre-existing disease 

- predisposes to articular cartilage failure

- failure of cartilage can be halted by decrease in load

- osteotomy corrects the underlying deformity

 

Pain relief achieved by

 

1.  Mechanical 

- decrease in unit load 

 

2.  Biological 

- decrease intra-osseous pressure

 

Conditions

 

1.  Dysplasia 45%

2.  Perthes   20%

3.  SUFE 10%

 

Indications

 

< 25 - 30 years

 

Natural History

 

OA by age 50 in

- 50% with DDH / Perthes

- 20% with SUFE

 

Aims

 

1.  Correct deformity

2.  Increase congruency / decrease unit load

3.  Decrease JRF

 

Types of Osteotomy

 

Direction

- varus / valgus

- flexion / extension

- combination

 

Reconstructive

- before OA begins

- age < 25 years

- Biological plasticity remains

- at-risk hip / painful hip ~ Ganz

- i.e. difficult to justify in the non painful hip

 

Salvage

- before end stage OA occurs

- age < 50 years

- pathogenesis secondary to malalignment

- moderate OA where congruence increased by osteotomy

 

Examination

 

ROM important

 

1.  Flexion / extension arc

- >/= 90° to consider osteotomy

 

2.  Abduction / adduction arc 

- correction should not exceed arc

 

Flexion / adduction contractures common

- correct with valgus / extension osteotomy

 

X-ray

 

AP pelvis

 

True lateral (Faux Profile) 

- lateral of pelvis with patient turned 25° to xray beam     

- to assess anterior uncovering

- VCA angle

 

Maximum Abduction / Adduction AP 

 

Von Rosen

- maximum abduction & IR

 

3D CT

 

Fluoroscopy

 

MRI 

 

Examine nature of joint surface

 

 

 

Techniques

Osteotomy Options

 

Varus

Valgus

Extension

Flexion / Internal Rotation

Neck Lengthening

 

Varus Osteotomy / Pauwels Type I

 

Indications

 

DDH 

- improve coverage

- rarely done alone

- only if little or no acetabular dysplasia

- CE > 15 - 20o

 

Perthes 

- improve coverage

 

AVN 

- if medial head involved (unusual)

 

Coxa Valga > 135°

- lateral subluxation of head

- signs of lateral overload i.e. eccentric sourcil

- adduction contracture

 

Requirements

- spherical head 

- increased congruity in max abduction

- minimum 15o abduction

 

Contraindication 

- lateral head osteophyte

 

Technique

- subtrochanteric osteotomy

- medial shaft displacement 10 - 15 mm

- 120o Synthes locking plate with offset

 

Valgus Intertrochanteric / Pauwels Type II

 

Indications

 

1.  AVN

- to unload anterolateral head

- usually valgus flexion

 

2.  Subcapital fracture nonunion

 

3.  Severe medial OA with medial osteophytes

- capital drop osteophyte

- inferomedial femoral head osteophyte

- acts as fulcrum against acetabular osteophyte

- widens the superolateral joint surface

 

4.  Coxa vara

- congenital / developmental

- fibrous dysplasia

 

5.  Protrusio in young patient

 

6.  Fixed abduction contracture

 

Requirement

 

90° flexion & 15° adduction

 

Technique

 

Calculate osteotomy

- mostly would be aiming for neck shaft angle 145 - 150o

 

Example coxa vara

- current neck shaft angle i.e. 110o

- desired neck shaft angle i.e. 145o

- require a 25correction

 

Fixation

- use a 145o plate and screw

- place screw in centre of femoral neck and head

- thus when fixate the plate on femoral shaft, will have obtained desired correction

 

Rotation

- mark proximal and distal femur with drill holes

- allows maintenance of current rotation / correction if required

 

Osteotomy

- use 2 K wires

- usually performed at level of lesser trochanter

- insert distal wire parallel

- insert second wire at desired angle

- check with II / angle measurement devices

- may wish to insert distal steinman pin to control distal fragment

- anterior and posterior homan retractors

- osteotomy with saw

 

Close osteotomy

- apply plate

- use compression device Synthes

 

Extension Intertrochanteric Osteotomy

 

Indication

 

In association with correction in coronal plane

Anterior uncovering of femoral head in DDH

FFD / flexion contracture

 

Effect

- improved anterior covering of head

- eliminates FFD

 

Flexion / Internal Rotation Intertrochanteric Osteotomy

 

Indication

 

Severe SUFE 

 

Technique

 

Imhauser Technique

 

 

 

Femoroacetabular Impingement

DefinitionHip CAM CT 1

 

Aberrant morphology involving the proximal femur and acetabulum

- usually between the femoral neck and the acetabular rim

- during terminal motion of the hip

 

Can cause pain secondary to labral and chondral lesions

- may lead to early OA

 

Aetiology

 

Childhood conditions

- Perthes

- DDH

- SUFE

 

Post trauma

- prior femoral neck fracture

 

Acetabular retroversion

- posteriorly orientated acetabular opening

- relative prominence of anterior rim

- crossing of anterior and posterior walls on the AP radiograph

 

Acetabular Crossover Sign

 

Previous periacetabular osteotomy

 

Coxa

- profunda (deep socket)

- breva

- magna

- vara

 

Protrusio

 

Types

 

Cam

Pincer

Mixed

 

Cam impingement 

 

Between head and acetabulum 

 

Abnormal femoral head morphology

- often with flexion

- damage to anterior labrum and shearing of cartilage (carpet lesions)

 

Usually young men

 

CAM lesion x-rayHip Cam LesionHip CT Anterior Cam Lesion

 

Pincer impingement 

 

Between neck and acetabulum

 

Hip Pincer Impingement

 

Due to overcoverage of femoral head

- profunda, protrusio

- acetabular retroversion / relative anterior rim overcoverage

 

Damage to anterior labrum

 

Epidemiology

 

Young active males

- CAM impingement

 

Middle aged athletic women

- pincer impingement

 

History

 

Groin pain

- with rest

- with activity

 

Pain with flexion

 

Clicking from labral tear

 

Examination

 

Typically limited ROM

 

AP impingement 

- IR / flexion /  adduction

- most common

 

Posteroinferior impingement

- full extension and external rotation

 

X-ray

 

True AP

- coccyx and symphysis pubis within 1-2cm of each other 

- for assesment of retroversion / crossover sign

- bony prominence junction anterolateral head and neck

- ossification of labrum

- acetabular spurs

 

Hip Cam Lesion Xray

 

Lateral 

- shows CAM

 

CT reconstruction

 

Very good for bony morphology

 

Case 1

 

CAM Lesion CT

 

Case 2

 

Hip Cam CT SagittalHip CT Cam 3DHip Cam CT 3D 2HIp Cam CT 3D 3

 

MRA

 

Labral lesions

 

Hip MRI Labral Tear CoronalHip CAM Anterior Labral Degenerative TearHip MRI Labral Lesion

 

Femoral head morphology / Alpha angle

 

T1 axial MRI

- circle drawn on circumference of femoral head

- line from centre to where head extends beyond circle

- line drawn to centre of femoral neck at its narrowest

- angle > 55o may be indicative of CAM

 

Hip MRI Anterior CAMHip CAM Alpha Angle

 

Beta angle

 

Distance between pathological head-neck junction and acetabular rim

- hip in 90o flexion

 

Management

 

Non Operative

 

Activity modification

Stretching

Usually problem does not resolve

 

Operative

 

Options

 

Open femoral head arthoplasty with surgical dislocation

Hip arthroscopy

 

Open femoral head arthoplasty

 

A.  Surgical dislocation of femoral head

 

Ganz Osteotomy

- preservation of blood supply

- deep branch of medial circumflex artery most important

- runs posterior to obturator externus

- emerges at superior border of quadratus femoris

- over short external rotators

- then retinacular vessels up anterosuperior neck

 

Approach

- must preserve short external rotators

- trochanteric osteotomy

- greater trochanter slid anteriorly

- has abductors and vas lateralis attached

- capsule divided in lazy S

- preserving capsule over anterosuperior neck 

- reflected subperiosteally off neck (like banana skin)

- dividing lig teres and dislocating hip

 

B.  Femoral head osteoplasty

- allow flexion of 120o

- rotation of 40o

 

3.  Acetabular debridement 

- debridement acetabular chondral flaps

- osteotomy of the acetabular rim (up to 1cm)

- reattachment / debridement of labral lesions

 

Arthroscopy 

 

Indications

- debridement of labral tears

- femoral head osteoplasty

 

Technique

 

Position

- patient supine

- foot IR full initially, leg extended

- traction applied

 

Hip Arthroscopy Portal Insertion II

 

Anterolateral viewing portal

- hip distracted

- under II vision

- guide wire in place

- dilators, insert cannula

 

Anterior working portal

- triangulate, using II

- anterior labral and CAM resection

 

Hip Arthroscopy Anterior Portal

 

Posterior working portal

- accessory for labrum and rim

 

Assess Cartilage

 

Hip Arthroscopy Chondral DamageHip Arthroscopy Carpet Lesion

 

Assess for Labral Tears

 

Hip Arthroscopy Degenerative Labral Tear From CAM lesionHip scope normal acetabular Labrum

 

Labral resection

- with long resector

 

Hip Arthroscopy Initial ViewHip Arthroscopy Post Labral Resection

 

Acetabular rim resection

- if necessary

- long burr

- difficult to know extent of resection required

- check on II

 

CAM resection

- flex hip, ER

- T capsulotomy to expose CAM lesion

- performed with long thin scapel

- burr resection of CAM lesion

- again, under II guidance

- put hip through range to ensure adequate debridement

- T capsulotomy exposes CAM well

- isolated reports of hip dislocation

 

Hip Arthroscopy Labral and Rim ResectionHip Arthroscopy CAM Lesion ExposedHip Arthroscopy CAM resection

 

FAI Cam Resection 1FAI Cam Resection 2FAI Cam Resection 3

 

Results

 

Labrum

 

Larson et al Arthroscopy 2009

- retrospective comparison of labral debridement v fixation in CAM / Pincer

- significantly improved hip scores in repair grou

- 67% G/E in debridement

- 90% G/E in fixation

 

Athletes with CAM

 

Singh et al Arthroscopy 2010

- 27 Australian Rules Playes

- treatment of chondral lesions / labral lesions / majority with CAM lesions

- high level of satisfaction and 26/27 returned to high level sport

 

OA

 

Byrd et al Arthroscopy 2009

- 10 year follow up

- 80% good results if no OA

- 7/8 with OA had THR at mean of 6 years

 

 

Hip Dislocation

IncidencePosterior Hip Dislocation

 

Young men

 

Posterior / Anterior 9:1

 

Aetiology

 

High velocity injury

- head direction at impact decides direction of dislocation

 

Anterior Dislocation 

 

Externally rotated & abducted leg

- flexion = inferior dislocation

- extension = pubic dislocation

 

Posterior Dislocation

 

Axial compression of adducted leg

- more flexion causes pure dislocation without fracture

 

Anatomy

 

Inherently stable joint

- large head on smaller neck

- allows deep seating of femoral head

- acetabulum deepened by labrum

- capsule reinforced by ilio/pubo/ischio femoral ligaments

 

40% femoral head in contact with articular cartilage

10% in contact with labrum

 

Blood supply

 

Majority by deep branch of Medial Circumflex Femoral Artery

- minimal by medial epiphyseal artery via ligamentum teres

- little to non via LCFA

 

MCFA

- arises medial aspect of profunda

- along posterior intertrochanteric crest extracapsular / back of femoral neck

- passes between iliopsoas and pectineus medially

- runs along inferior border of obturator externus, above adductor brevis

- deep to quadratus femoris

- emerges between quadratus and inferior gemellus

- runs over conjoint tendon (2 gemelli and obturator internus)

- then penetrates capsule between conjoint and piriformis

- runs along superior aspect of neck to femoral head

 

Transverse branch (to ischium) and ascending branch (to trochanteric fossa0

- arise anterior to quadratus

 

Must protect this deep branch MCFA in a posterior approach

 

With dislocation and capsular tears

- some ascending cervical branches stretched/kinked

- emergent reduction can improve blood flow to femoral head

 

Associated Injuries

 

50-95% have other injury

 

Acetabular fracture

 

Femoral head fracture / Pipkin fracture

 

Sciatic nerve 10% / posterior dislocation

 

Patella fracture

 

PCL

 

Femoral artery injury - anterior dislocation

 

Femoral shaft fracture

- reduce head via steinman pin in proximal fragment

- then IMN femur

 

Classification

 

Direction

 

1. Medial / Central

- really medial displacement with acetabular fracture

 

2. Anterior 

- pubic / obturator / perineal

 

3. Posterior

 

Posterior Hip Dislocation Lateral

 

Pathoanatomy

 

Capsule & Ligamentum teres torn

 

Labral tears & muscular injuries also occur

 

Y / iliofemoral ligament often intact with posterior dislocation

- blocks reduction

- bony fragments also block reduction

 

Clinical Features / Xray

 

Posterior dislocation

- leg shortened, flexed, adducted & internally rotated 

- head small on xray

 

Posterior Hip Dislocation

 

Anterior dislocation 

- leg short and externally rotated

- head larger on xray

 

Check NV status / sciatic nerve

 

Management

 

Immediate

 

Assess & manage life threatening injuries

- EMST / ATLS principles

 

Principles

 

1. Emergent reduction

- closed +/- open

- reduce risk AVN 

 

AVN

- < 6 hours 10%

- 20% - 50% if >24 hours

 

2.  Assess stability

 

Posterior wall fracture > 40%

- need ORIF for stability

 

Hip Dislocation Posterior Wall FractureHip Dislocation Posterior Wall Fracture

 

Posterior wall fracture < 40%

- can be unstable

- EUA after reduction to assess stability

- should be able to flex to 90o and some IR without instability

 

3. Screen for retained fragments

 

Compulsory CT

- xray will not detect fragments < 2mm

 

Hip Dislocation Loose Body

 

Remove / ORIF depending on size of fragment and location / Pipkin type

 

4. Reconstruct acetabulum if unstable or incongruent

 

Closed Reduction Posterior Dislocation

 

Technique

 

Full muscle paralysis on radiolucent table 

- supine

- assistant places downward pressure on ASIS

- operator up on bed grasping leg

- flex hip to 90o, flex knee to 90o

 

Technique

- ER head around acetabulum / axial traction or

- IR head around acetabulum / axial traction

 

Post reduction

- check concentric reduction on II

- check stability in flexion

 

Unstable reduction

- skeletal traction / femoral steinman pin

 

Post op

 

NV examination when patient awake

- ensure sciatic nerve working

- ensure hasn't become entrapped with reduction

 

CT

 

Closed Reduction Anterior Dislocation

 

Technique

- as above

- traction in line with femur flexed

- internal rotation maneuver

 

Irreducible Dislocations

 

Incidence

- 2-15%

 

Causes

 

1.  Capsule / Labrum / Ligamentum teres

2.  Muscle interposition

- anterior usually rectus / psoas

- posterior usually piriformis / G maximus

3. Bone fragment

4.  Muscle tone

- patient requires relaxant

 

Management

 

Open reduction

 

Non-concentric Reduction

 

Esssential to obtain X-ray and CT after reduction

 

X-ray

- head - teardrop distance must equal contralateral side

 

CT

- only with CT can < 2mm fragments be seen

 

Pipkin Infrafoveal CT

 

MRI

- may be needed to see labral tears blocking reduction

 

Open reduction

 

Indications

 

1.  Irreducible dislocation

 

2.  Non-concentric reduction

- loose bodies / interposed tissue

 

3.  Post operative sciatic nerve palsy

 

4.  Unstable posterior acetabular fracture

 

5.  Associated NOF fracture

 

6.  ORIF Pipkin fracture

 

Approach 

 

Usually from direction of dislocation

- preserve intact capsule

- preserve remaining blood supply

- i.e. with posterior dislocation the posterior capsule will be torn

- provides entry into joint

 

Posterior Approach

 

Aim to preserve intact anterior capsule and blood supply

- beware sciatic nerve

- divide piriformis and conjoint tendon away from insertion to preserve deep branch MCFA

- may need to extend posterior capsular rent

- allows direct visualisation of blocks to reduction

- blocks include G. max, piriformis, capsule, bony fragments

- may need to excise ligamentum teres

- explore acetabulum for loose bodies

- close capsule afterwards

- may need to excise L Teres

 

Other issues

 

Posterior acetabular fracture

- ORIF if > 40% or unstable

 

Pipkin fracture

- manage as per Femoral Head Fractures

 

Subcapital fracture

- Watson Jones / Smith Peterson approach

- supplementary lateral approach to insert fixation

 

Post Operative

 

NWB for 6/52

 

Bone scan re vascularity 

 

Issue

- °AVN = FWB

- AVN = consider bisphosphonates

 

Yue et al J Orthop Trauma 2001

- 5/54 low blood flow on early SPECT

- no correlation with AVN

 

Complications

 

AVN

 

Related to

- time to reduction <12/24

- velocity of injury

- open reduction vs closed (x4)

- direction (anterior < posterior)

 

Timing

- < 6/24 = 2-10%

- > 12/24 = 52%

 

Direction

- posterior 17%

- anterior 2%

 

Tends to be localised

- revascularisation occurs on reduction

- damage to lateral & medial epiphyseal artery

- metaphyseal blood supply remains

- occurs in first 18 months

 

OA 

 

Incidence

- 15 - 20 %

 

Causes 

- AVN

- instability

- incongruous reduction

- cartilage damage at time of dislocation

 

Philippon et al Arthroscopy 2009

- hip arthroscopy post traumatic dislocation in 14 athletes

- all had chondral defects, 11 had loose fragments

- all patients had labral tears

 

Sciatic Nerve Palsy 

 

Posterior dislocation

- 8 - 19%

- more common after fracture / dislocation

 

Type

- usually partial CPN

- usually resolves

 

Only explore if onset after MUA

 

Else observe

 

Instability < 1%

 

Myostitis Ossificans

 

Uncommon

- usually little functional problem

Hip Fractures

Intertrochanteric Fractures

DefinitionHip Intertrochanteric Fracture Type 3

 

Fracture which extends between the trochanters of the proximal femur

- lower limit is inferior border of lesser tuberosity

 

Anatomy

 

Extra capsular / well vascularized

 

The key to stability is the posteromedial cortex

 

Epidemiology

 

Elderly

- 90% > 65

- peak at 80 years

 

F:M 2:1

 

NHx 1st year

- 1/3 die

- 1/3 worse function

- 1/3 same function

 

Mechanism of injury

 

Low energy injuries in osteoporotic patient

- direct = blow to GT

- indirect = torque force secondary to fall

 

Signs

 

Leg

- shortened

- externally rotated

- groin pain with leg movement

 

Prevention

 

Judicious use of medications

- avoid confusing / sedating

 

Poor vision

- adapt home environment

- avoid slippery rugs etc

 

Adapt bathrooms for safety / stability

 

Hip pads

 

Dx Occult Hip Fractures

 

Definition

 

Hip pain

Normal Xray

 

Investigations

 

CT scan

- easily obtained in emergency departments

 

Bone Scan

- 100% sensitive at 72 hours

 

MRI

- sensitive within 24 hours

- more expensive and difficult to obtain

 

Results

 

Lubovsky et al Injury 2005

- compared CT and MRI

- MRI more accurate

- 4/6 CT inaccurate

 

Evans Classification 

 

Two main types

- Type 1 Intertrochanteric

- Type 2 Reverse Oblique

 

Stability

- depends on medial cortical reduction

 

Unstable

- collapse into varus or shaft medialises

- comminuted PM cortex

- reverse oblique

- subtrochanteric extension

 

Type 1 Intertrochanteric

 

1.  2 part undisplaced & stable

 

Hip Intertrochanteric Fracture Type 3

 

2.  2 part displaced, but stable on reduction

 

Hip Displaced Intertrochanteric Fracture

 

3.  3 part with posterolateral support (GT fracture)

 

4. 3 part without posteromedial support (LT fracture)

 

Hip Intertrochanteric fracture Type 4

 

5. 4 part without posterolateral or medial support (combination 3 and 4)

 

Four Part Inter trochanteric fracture

 

Type II Reverse Oblique Type

 

 

Inherently unstable

- 2° tendency of femoral shaft fragment to shift medially

 

Modified Boyd Classification

 

Type I   21%

- nondisplaced & stable 

 

Type II   36%

- stable, but displaced fractures

- stable construct with pin and plate

 

Type III   28%

- unstable with pin and plate

- large posteromedial comminution 

 

Type IV  15%

- intertrochanteric with subtrochanteric component

 

Isolated GT Fracture

 

Isolated Greater Trochanter Fracture

 

Management

 

Non operative

 

Issues

 

Little place for non operative treatment

 

Immobilization = Severe morbidity

- bed sores

- chest infection

- non-union

 

Indications

 

Unit for surgery

 

Incomplete fractures

 

Alam et al JBJS Br 2005

- 5 partial intertrochanteric fractures treated non operatively, 3 operatively

- no refractures

- similar length of hosptial stay

 

Operative

 

Medical Workup

 

1.  Improve any reversible medical disease

 

Otherwise surgery in first 24 hours

 

Consider Cause of fall

- exclude medical cause

- TIA / UTI / MI / Arrythmia

 

Treat

- electrolyte imbalance / anaemia

- pneumonia / UTI

- arrythmias

 

2.  Patient on anticoagulation

- operate if on plavix

- on warfarin, wait or use FFP to reduce INR < 1.6

 

Timing

 

Zuckerman et al JBJS Am 1995

- delay > 2 days increases mortality within the first postoperative year

 

Goal

 

Obtain stable anatomical reduction and allow early mobilisation

 

Options

 

Sliding Hip Screw and Plate

Intramedullary Hip Screw

Calcar Replacing Prosthesis

 

Post operative

 

Mobilise +++

 

DVT prophylaxis

- chemical and mechanical

 

Nutrition

 

Foster et al J Orthop Trauma 1990

- higher morbidity if albumin< 3 (70%) than > 3 (17%)

 

Prevent secondary fractures

- vitamin D + calcium to all patients

- bisphosphonates if tolerated

 

Sliding hip screw and Plate

 

Hip Pin and Plate APHip Pin and Plate Lateral

 

Mechanism

 

Plate is a lateral tension band whilst the sliding screw allows controlled fracture impaction

 

Contraindications

1.  No lateral buttress 

2.  Reverse oblique fracture

3.  Subtrochanteric extension

 

Technique

 

Set up

- traction table with anatomic reduction

- traction, adduction, IR

- other leg: hip and knee flexed with hip abducted to allow II

- lateral approach to femur

 

Guide wire

- centred in femoral head in 2 planes 

- tip-apex distance < 25 mm

 

Tip - apex distance

- from tip of screw to apex femoral head

- accumulative on AP and lateral

- strong predictor of cut out

- < 25 mm, virtually zero

- > 25 mm, increases cut out

 

Measure angle

- wire in centre of neck / centre of head

- usually 130o prosthesis

- often only 135o available / need to be lower in neck

- being in the centre of the head is most important

 

Ream to within 5 mm of end of wire

- tap

- insert screw / tip apex distance < 25 mm

- attach plate

 

Options for improving stability

 

A.  Valgus Osteotomy for unstable Fractures

 

Theory

- reduces shear force

- increases compression

- stronger construct

 

Technique

- 135° plate placed in at 120°

- valgises proximal fragment 

- medializes shaft

- +/- lateral wedge removed / Sarmiento Valgus Osteotomy

 

Cochrane Database Sytemic Review 2009

- no evidence for improved outcome

- higher blood loss

 

B.  Trochanteric stabilisation plate

 

Theory

- buttresses the GT and prevents lateral displacement

 

Madsen et al J Orthop Trauma 1998

- compared first generation Gamma nail / CHS and DSH/TSP in unstable fractures

- DHS/ TSP had lowest rate of varus malunion / lag screw cutout / excessive lag screw sliding with medialisation

- CHS still had lowest rate of reoperation

 

Intra-medullary Hip Screw

 

Hip Intertrochanteri Fracture IMNHip Intertrochanteric IMN Lateral

 

Mechanical Advantages

- load sharing rather than load bearing

- decreases lever arm

- supports medial cortex

- less distance for collapse

 

Theoretical Surgical Advantages

- smaller incision / mini invasive

- reduced blood loss

- shorter surgical times

 

Indications

- reverse oblique

- unstable fracture / loss of lateral buttress / loss posteromedial support

- intertrochanteric extension

- pathological fractures

 

History

 

First generation Gamma Nail (Stryker) had 5% distal femoral fracture rate

 

Reasons for distal fracture

- fit and fill caused increased distal stresses (higher fracture with 16 mm diameter nail)

- no anterior bow

- poor distal locking technique (missed holes caused fractures)

- 2 distal screws

 

Second Generation intra-medullary hip screws

 

IMHS / Gamma Nail

- trochanteric entry

- decreased distal diameter

- shorter length (180 mm v 200mm)

- only 4o valgus offset

- 125 - 130o angle

- one distal screw with jig

 

Hip Reverse Obliquity Fracture IMN

 

Results

 

Second Generation IMN v Sliding hip screws

- several prospective randomised studies

- very similar rates of complications

- similar cut out, blood loss, time of operation

- slight risk femoral fracture IMN

- learning curve for IMN (25 cases)

 

Cochrance database review 2008

- no evidence of superiority of IMN over sliding hip screw

- increased complications with nail

 

3.  Calcar replacing prosthesis

 

Indications

- salvage of failure of fixation

- severe comminution

- RA

 

Problems

- high cost

- higher morbidity / mortality

- high risk of dislocation

 

Complications

 

1.  Screw Cut Out 6%

 

Hip Pin and Plate Screw Cut outIntertrochanteric NOF Screw Cut out

 

Causes

- poor screw position

- 150° screw

- high tip apex distance

 

Options

- 95o DCS

- THR / calcar replacing prosthesis

 

THR Issues

 

A.  Cemented femoral component

- cement will come out screw holes

- Option 1:  leave screws in laterally, and strip medially to insert small screws

- Option 2:  use uncemented stem

 

B.  Length of femoral stem

- should bypass distal screw hole by 2 cortical diameters

 

C.  Calcar

- normal stem usually sufficient if LT healed back on

 

THR Post Pin and PlateIntertrochanteric NOF Calcar Replacing THR

 

Barrel Impingement / Excessive Lateral sliding / Shaft medialisation

 

Cause

 

1.  Long screw

2.  Collapse with insufficent lateral buttress

3.  Reverse obliquity fracture

 

Intertrochanteric Fracture Barrel Impingement

 

Management

 

1.  Fracture united

- remove screw

 

2.  Fracture non union

- revise fixation in young patient

- THR

 

Lateral Slide Off Proximal Fragment

 

Femoral medialisation

 

Due to

- insufficient lateral cortex

- reverse obliquity fracture

 

Use 95° plate

 

Non Union

 

Uncommon / 1%

- exclude infection

 

Presentation

- continued pain (case 1)

- hardware failure (case 2)

 

Case 1

 

NOF Intertrochanteric Non unionNOF Intertrochanteric Nonunion CT

 

Case 2

 

Hip Broken Intertan NailHip Broken Intertan Non Union salvage

 

Options

 

A. Closing lateral wedge valgising osteotomy + graft

- success 90% / indicated in younger patients

B.  95 degree DCS Plate

C.  Revision IMN

D.  THR

 

Infection 2-5%

 

Intertrochanteric Infected NonunionIntertrochanteric Infected Nonunion Spacer

 

Malrotation

 

Cause

- posterior sag of femur in unstable fracture

- get malrotation if use excessive IR to "reduce" fracture on II

 

Periprosthetic fracture

 

Usually fracture at tip of plate

- remove distal screws and insert retrograde nail

 

Subcapital Fractures

Background

DefinitionGarden 3 Displaced Subcapital

 

Fracture distal to articular surface & proximal to intertrochanteric region

 

Epidemiology

 

On average 4 years younger than intertrochanteric fracture

 

One year mortality as high as 36%

 

Only 1/3 will return to pre-fracture living environment

 

Mechanism of Injury

 

Direct or Indirect

 

1.  Direct blow GT 

 

2.  Posterior cortex impingement on rim

- 2° to ER

- acts as a fulcrum

 

3.  Bending torque > threshold 

- major trauma in young

 

4.  Violent muscle contraction

 

5. Cyclical loading / Insufficiency fracture

 

Risks

 

Osteoporosis

Osteomalaica

Co-morbidity

Dementia

Poor mobility / vision

 

Blood Supply

 

Medial and lateral circumflex femoral arteries

- extracapsular anastomosis at base of neck

- retinacular / ascending cervical branches

- intra-capsular branches

 

Majority via MCFA

- almost none to head via LCFA

- small amount via medial epiphyseal via ligamentum teres

 

MCFA

- medial aspect of profunda

- along posterior intertrochanteric crest extracapsular

- between iliopsoas laterally and pectineus medially

- runs along inferior border of obturator externus, deep to quadratus femoris

- emerges at superior aspect quadratus femoris

- runs anterior to conjoint tendon then penetrates capsule

- runs along superior aspect of neck

 

LCFA

- arises lateral aspect of profunda

- transverse branch runs under sartorius and rectus over vas lateralis to supply proximal femur

 

Garden's Classification

 

Type I 

 

Incomplete valgus impacted fracture

 

Subcapital NOF Garden 1 CTSubcapital NOF Garden 1 Xray

 

Type II 

 

Complete fracture, undisplaced

 

Type III 

 

Displaced with capsule intact 

- trabeculae don't line up with acetabulum

 

Subcapital NOF Garden 3

 

Type IV 

 

Displaced 

- trabeculae line up with acetabulum

 

Subcapital Fracture Garden 4

 

Eliasson Acta Orthop Scanda 1988

- best to divide into displaced / undisplaced

- based on work showing poor interobserver reliablity with Garden's

 

Pauwel's Classification

 

Relates vertical shear vector

- more vertical the fracture

- increased risk of non union

 

Type I:    < 30° from horizontal

Type II:   30 - 50° from horizontal

Type III:  > 50° from horizontal 

 

Subcapital Fracture Pauwels Type III

 

Problem 2° to parallax error

 

Complications

 

AVN

 

Undisplaced < 10%

Displaced 20 - 33% (variable, not complete)

 

Non union

 

Undisplaced 5%

Displaced up to 33%

 

This complication is more likely to need surgery

 

Clinical presentation

 

Pain

 

Short & ER leg

 

Management

 

Medical Workup

 

1.  Improve any reversible medical disease

 

Otherwise surgery in first 24 hours

 

Consider Cause of fall

- exclude medical cause

- TIA / UTI / MI / Arrythmia

 

Treat

- electrolyte imbalance / anaemia

- pneumonia / UTI

- arrythmias

 

2.  Patient on anticoagulation

- operate if on plavix

- on warfarin, wait or use FFP to reduce INR < 1.6

 

Management

 

Algorithm

 

Displaced v undisplaced

Age of patient

 

Undisplaced Subcapital

 

Cannulated screws

DHS + derotation screw

 

Displaced Subcapital Algorithm

 

1.  Expected life > Prothesis Survival

 

ORIF

- anatomical reduction / closed or open

- compressive screws / DHS + derotation screw

 

2.  Expected life < Prothesis Survival

 

Hemiarthroplasty < 5 years survival

THR 5-15 years survival

 

Rogmark et al JBJS Am 2002

- multicenter RCT patients > 70 years with displaced fracture

- ORIF 43% failure

- hemiarthroplasty 6% failure

 

Displaced Arthroplasty

Indications

 

Patient > 70

 

Gjertsen et al JBJS Am 2010

- 4335 patients > 70 with displaced subcapital fractures

- minimum 1 year follow up

- 1 year mortality same in each group / 25%

- 22% reoperation in ORIF v 3% in hemiarthroplasty

- more pain / higher dissatisfaction / lower quality life in ORIF group

 

Options

 

Hemiarthroplasty

- unipolar monoblock

- unipolar modular

- bipolar

 

THR

 

Burgers et al Int Orthopaedics 2012

- THR v hemiarthroplasty

- 8 trials involving nearly 1000 patients

- THR 4% revision v HA 7% revision

- THR 9% dislocation v HA 3%

- THR 94 WOMAC v 78 HA

 

Hopley BMJ 2010

- THR may lead to lower reoperation rates and better functional outcomes compared with HA in older patients

- heterogeneity across the available trials preclude definitive statements

 

Ingull Int Orthop 2013

- RCT of cemented unipolar v bipolar HA

- 4 year follow-up in 120 patients aged 80 or more

- better EQ-5D in bipolar

- no difference in revision rates / acetabular erosion / HHS

 

Li et al PLoS One 2013

- meta-analysis of cemented v uncemented HA in elderly

- cemented better hip function, less postoperative pain, fewer intra-operative complications but longer surgical time

- no difference in revision rate

 

Australian Joint Registry 2010 Revision Rates

 

1.  > 85 

- unipolar monoblock 3.4% 7 years

- unipolar modular 2.1% 5 years

- bipolar 2.9% 7 year

 

2.  75-84

- unipolar monoblock 8.5% 9 years

- unipolar modular 5.5% 7 years

- bipolar 3.5% 7 years

 

3.  < 75 

- unipolar monoblock 17.5% 7 year

- unipolar modular 13.4% 7 year

- bipolar 6% 7 year revision rate

 

Hemiarthroplasty

 

Issues

 

Types

 

Unipolar

- non modular - Austin Moore / Thompsons /

- modular

 

Bipolar

 

Fixation

 

Cement

- minimises fracture risk

- reduced risk thigh pain

- slightly increased cardiac risk with cement

 

Australian Joint Registry

- revision rates lower for cemented than uncemented

- for all types of hemiarthroplasty for NOF fractures

 

Approach

 

Posterior approach

- increased short term morbidity

- may increase dislocation risk

 

Hardinge

- take off anterior 1/3 abductor tendons

 

Prosthesis Options

 

Austin Moore

- press fit non modular unipolar

- only 2 sizes of stem

- small patients can fracture femur

- larger patients the stem can be loose

- AJR: 7.8% 9 year revision rate

 

Hip Austin Moore

 

Thompson's

- cemented non modular prosthesis

- no offset options

- AJR: 5.1% 7 year revision rate

 

Thompsons Hemiarthroplasty

 

Modular Unipolar

- based on standard THR concepts

- trial and insert femoral component / cemented or uncemented

- can use standard or high offset

- opportunity to adjust neck length

- attach head

 

Modular Hemiarthroplasty

 

Bipolar 

 

Hip Bipolar

 

Concept

- metal femoral head articulates with polyethylene socket

- reduces motion at acetabular / metal interface

- in theory reduces acetabular cartilage wear / degeneration / pain

 

Advantages

- less dislocation compared with THR

- less acetabular wear / protrusio compared with unipolar

- less pain compared with unipolar

- more motion

- lower revision rates compared with unipolar (AJR)

 

Disadvantage

- high cost (close to some THR)

- may need open reduction in dislocation if femoral head disassociates from socket

- loss of motion interface / becomes unipolar)

 

Complications

 

Infection

 

Dislocation

- similar to THR in long term

 

Hemiarthoplasty dislocatedBipolar Dislocation

 

GT Fracture

 

Hip Hemiarthroplasty GT Fracture

 

LLD

 

Hip Hemiarthroplasty LLD

 

Loosening

 

Groin pain from acetabular cartilage erosion

- most common complication

 

Severe acetabular wear

 

Bipolar Acetabular Destruction 1Bipolar Acetabular Destruction 2

 

Bipolar Acetabular Destruction Revision 1Bipolar Acetabular Destruction Revision 2

 

THR

 

Indications

 

Acetabular disease (RA, Paget's, OA)

Young, active, mobile patient

 

Issues

 

1.  Dislocation

 

Increased early dislocation rate

Long term dislocation rate similar to hemiarthroplasty

 

Keating et al Health Technol Assess 2005

- randomised study of bipolar v THR

- 2.7% dislocation rate v 4.3%

 

2. Revision / Survivorship

 

Good long term survival

 

Lee et al JBJS Am 1998

- 94% 10 year survival

 

3. Function

 

Parker et al Cochrane Database Review

- THA has better functional outcome

 

Bekerom et al JBJS Br 2010

- RCT of hemiarthroplasty v THR in over 70

- 252 patients 5 year follow up

- no difference in Harris Hip scores, revision rate

- increased early and late dislocation in THR

- did not recommend THR in over 70

Displaced ORIF

Indications

 

< 60 with good bone stock and preserved joint space

 

Reduction

 

Union rates increased with anatomical reduction

 

Options

- closed reduction

- open reduction / if closed reduction fails

 

Accept

- no varus

- < 15o valgus

- < 10o AP plane

 

Assessment of reduction

 

1.  Femoral neck shaft angle

 

2.  Garden alignment index

- angle of compression trabeculae to femoral shaft on AP should be 160o

- angle of compression trabeculae to femoral shaft on lateral should be 180o

 

3.  Lowell's alignment theory

- head neck junction should make a smooth S / reverse S on all views

 

4.  Restoration of Shentons line

 

Closed Reduction

 

Set up

 

Traction table / radiolucent table

 

Leadbetter Maneuver

 

FATI CAR

- flexion / adduction / traction / IR 

- circumduction / abduction

- reduction Check in extension

- "Foot in Palm Test"

- if sufficiently reduced will sit without ER

 

ORIF

 

Cannulated screws / DHS + derotation screw

 

Aminian JOT 2007

- biomechanical study of strength of fixation of vertical fractures

- locking plate > dynamic condylar screw > dynamic hip screw / 3 cannulated screws

 

Capsulotomy

 

Theory

- decrease intracapsular pressure

- in animal models increases blood flow

 

Options

- open capsulotomy via Smith Peterson

- percutaneous needle drainage of hematoma

 

Open Reduction

 

Set up

 

Radiolucent table

- floppy lateral with sandbag under affected hip

 

Technique Watson Jones approach

 

Lateral incision

- divide fascia lata

- interval between G medius and TFL

- can take some of G medius off to aid exposure

- flexing hip 20-30o helps exposure

- take reflected head of rectus femoris off anterior capsule

 

"T" ant capsulotomy / Z shaped

- avoid dissecting superior aspect of femoral neck where major artery of MCFA runs

- vertical limb down anterior edge acetabulum / preserve labrum

- horizontal limb along inferior aspect of femoral neck

 

Steinman pin in femoral head

- allows manipulation and reduction

- may need second steinman pin in femur

- obtain anatomical reduction under direct vision

 

Separate lateral approach

- split ITB and vastus lateralis

- fixation of reduction

 

Check reduction on II

- ensure no varus on AP

- obtain lateral by adducting and IR hip / ensure good reduction on lateral

 

Ensure 2 guide wires centrally in femoral head

- 2 hole DHS + derotation screw (strongest)

- 3 or 4 cannulated screws

 

Open subcapital ORIF

 

Technique Smith Petersen

 

Smith Petersen Approach 1Smith Petersen Approach 2Smith Petersen Approach ORIF

 

Options

 

Unstable fracture

- augment with a plate on inferior neck

 

Displaced Subcapital Inferior PlateDisplaced ORIF Lateral

 

Results

 

Age

 

Rogmark et al JBJS Am 2002

- multicenter RCT patients > 70 years with displaced fracture

- ORIF 43% failure

- hemiarthroplasty 6% failure

 

Timing

 

Jain et al JBJS Am 2002

- retrospective review of displaced fractures in 29 patients < 60

- significant reduction in AVN if fixed within 12 hours

 

Complications

 

AVN

 

Subcapital NOF AVN

 

Incidence

 

Undisplaced <10%

Displaced  20-33% 

 

Risk factors

 

Displacement

Injury velocity

Delay in Reduction

Non-anatomical Reduction

 

Pathology

 

Whole head or small wedge 

- most common anterosuperiorlateral

 

Revascularization  

- existing med and lateral epiphyseal blood vessels

- metaphyseal BV crossing fracture

- reduced by mal-reduction / non union

 

Only 30% with AVN will need re operation

 

Management Options

 

Older patient

- arthroplasty

 

Younger patient

- forage / vascularized fibula graft / non vascularised bone graft

- osteotomy

 

Non-Union

 

Incidence 

 

9-33%

 

Risk Factors

 

Intial displacement

Non anatomical reduction

Instability

No compression across fracture

Vascularity - can unite if avascular

 

Failed Subcapital ORIFSubcapital ORIF Lateral

 

Subcapital Nonunion 1Subcapital Nonunion 2

 

Management

 

Older patient

- arthroplasty

 

Young patient

- valgus osteotomy

 

Subcapital NOF Non UnionSubcapital NOF Nonunion CTTHR post Subcapital Nonunion

 

Valgus osteotomy

 

Indications

- patient must have at least 15o adduction

 

Template

- aim to reduce the angle of the neck fracture to between 20 - 30o from horizontal

- this places it perpendicular to the forces acting across the hip

- measure angle of fracture from horizontal (usually 40 - 50o up to 70o)

- difference is angle of correction (20 - 30o)

 

Technique

- insert guide wire in centre of head / for screw

- place K wire superiorly in same plane as this wire at level of LT

- second K wire below at angle of required osteotomy

- resect bone piece

- apply appropriately angle device

- ensure straight line down femur in AP and lateral if need subsequent THR

Undisplaced Management

Definition

 

Garden 1 / 2

 

Algorithm

 

ORIF

- ~ 15% displacement rate with non operative management

- increased risk of non union

- reduced hospital in patient stays

 

Options

 

Cannulated screws

DHS + derotation screw

 

3 cannulated screws

 

Hip Cannulated Screws

 

Technique

- lateral on traction table

- adequate reduction / no varus

- small incision

- 1 x inferior screw, 2 x superior screws

- ensure inferior screw entry is above LT to prevent fracture

- ensure threads cross fracture site entirely to obtain compression

- need correct screw length so screw head can compress against cortex

 

DHS and derotation screw

 

Subcapital Fracture DHS Derotation Screw

 

Results

 

Parker et al Acta Orthop Scand 1998 69

- meta-analysis of 25 randomised trials

- no superiority of pin and plate over 3 cannulated screws

- less blood loss with cannulated screws

 

 

 

 

Subtrochanteric Fractures

Definition

 

Fracture below lesser trochanter / proximal 5 cm femur

 

 Subtrochanteric Fracture Long SpiralSubtrochanteri Fracture

 

Aetiology

 

Young patients / high velocity injuries

Old patients / osteoporosis

 

Fixation techniques

 

Plate

 

A. 95o Dynamic Condylar Screw / DCS plate

 

Indication

- revision

- very short proximal fragment

 

Pai J Orthop Trauma 1996

- 16 cases without no bone graft

- union in 15/16

 

B. Locking plates

 

Burkes JOT 2012

- 18 pertrochanteric fractures treated with Synthes locking plate

- catastrophic failure in 7 (37%)

- poor Harris Hip Scores in remainder

- postulated that construct too stiff

 

Forward JOT 2012

- biomechanical comparison of subtrochanteric fixation

- IMN strongest

- 90 degree condylar and locking plate similar strengths

 

IMN

 

Cephalomedullary nails / screws into femoral head

- reconstruction nail

- IMHS / Gamma Nail / Intertan

 

Advantage

- load sharing

 

Subtrochanteric Intertan NailSubtrochanteric Femur Fracture Gamma NailReconstruction NailReconstruction Nail Spiral Blade

 

Outcomes

 

Lee et al J Trauma 2007

- RCT of DCS v recon nail in 66 young patients with comminuted subtrochanteric fractures

- no significant difference in union rates

 

Rahme et al J Orthop Surg 2007

- RCT 58 patients

- revision rate 28% in plate group v 0% in IMN

 

Technique IMN

 

Issue

 

Varus position associated with non union

 

Shukla Injury 2007

- case series of subtrochanteric fractures treated with IMN

- all nonunion occured with varus > 10 degrees

 

Deformity

 

Subtrochanteric FractureSubtrochanteric Lateral

 

Usual with short proximal fragments

- proximal fragment abducted, ER and flexed

- difficult to obtain trochanteric entry and straight shot down femur

- tendency for guide wire to go medial

- difficult to avoid fixing proximal fragment in varus

 

Reduce proximal fragment first

- avoid lateral entry on trochanter

- avoid varus

- allows accurate passing of guide wire

 

Reduction techniques

 

Percutaneous

- ball tipped spikes / steinman pin to proximal fragment

- reduce varus

 

Open

- percutaneous clamp / temporary reduction of fracture

- cerclage wiring - involve soft tissue stripping / may block femoral head screws

 

Cerclage wires

- can hold reduction

 

Afsari JBJS Am 2010

- cerclage reduction of displaced subtrochanteric fractures

- 43/44 fracture united

- good outcomes, if soft tissue dissection minimized

 

 Subtrochanteric Varus APSubtrochanteric Femur Varus Lateral

 

Complications

 

Varus Malunion

 

Causes

- trendelenberg gait

- LLD

- increases risk non union
 

Malreduction

 

May need to open reduce fracture before nailing

 

Subtrochanteric Fracture Malreduced0001Subtrochanteric Fracture Malreduced0002

 

Non union

 

Subtrochanteric Fracture Nonunion

 

Causes

 

Non antomical reduction (varus / flexion / persistent displacement)

Excessive soft tissue stripping

Infection - must exclude with blood tests

 

Presentation

 

Pain

 

Failure Hardware / Broken nail

- use guide wires with hook at tip

- catch distal end of nail and retrieve

 

Management Options

 

A. 95 degree condylar plate

- reduction of malunion / takedown non union

- bone graft

 

Subtrochanteric NonunionDCS 95 degree

 

B.  Exchange nailing

- need to be able to obtain reduction

 

Subtrochanteric non union Broken IntertanSubtrochanteric Nonunion Revision Nail

 

C.  THR / calcar replacing

 

Calcar Replacing Prosthesis

 

Screw Cutout

 

Recon Nail Cut outRecon Nail Cutout LateralRecon Nail Cutout Salvage

Outcome Measures

Please refer to excellent website for details of all scores

www.orthopaedicscores.com

 

1.  Disease specific outcome measures

 

Surgeon assessment

Traditional

 

Harris Hip Score

 

JBJS Am 1969

 

A.  Patient History (90 points)

- pain, walking distance, limp, support

- stairs, sitting, shoes, public transport

 

B.  Patient Examination (10 points)

- ROM values

 

Score

- < 70 poor

- 70 - 80 fair

- 80 - 90 good

- 90 - 100 excellint

 

Mayo Hip scores

 

80 points clinical

 

20 points xray

 

2.  Patient specific outcome measures

 

Assesses broader range of issues

- patient assessment

 

Oxford Hip scores

 

Assess

- pain

- function

- ROM

 

Entirely patient history

 

SF-36

 

Medical outcomes short form 36

 

WOMAC

 

Western Ontario McMaster Osteoarthritis Index

Symptoms / Pain / Function

 

 

 

Pelvic Fractures

Background

Anatomy

Pelvis Anatomy

 

Pelvis is a true ring

- any anterior fracture must have a posterior injury as well

- integrity of the posterior sacroiliac complex is key

 

Bony Anatomy

 

2 innominate bones + sacrum

Symphysis pubis < 5mm

SI joint 2-4 mm

 

Soft Tissue Anatomy

 

Suspension bridge like complex of post ligaments

 

1.  Posterior sacroiliac ligaments 

- are strongest in body

- maintain sacrum in position in pelvis

 

2.  Anterior sacroiliac ligaments

- flat and strong 

- resist ER and shearing forces

- they do not have the strength of posterior ligaments

 

3.  Iliolumbar ligaments 

- iliac crest to transverse process of L5

 

4.  Sacrospinous ligaments

- transversely from lateral edge of sacrum to ischial spine

- resist ER of pelvis

 

5.  Sacrotuberous ligaments 

- from sacroiliac complex posterior to sacrospinous ligament

- pass down to ischial tuberosity

- resist vertical shear

 

Sacrospinous and Sacrotuberous are complementary 

- running at 90o to each other 

- adapted to the major forces acting upon the pelvis

 

Injury Patterns

 

Mechanisms

 

ER

IR

Vertical shear

 

Young and Burgess Classification

 

APC / Anterior Posterior Compression

 

APC 1 - 1-2 cm diastasis, minimal SIJ diastasis anteriorly

 

Pelvic Fracture APC 2

 

APC 2 - ST/SS + anterior SIJ disrupted

 

Pelvis APC 2Pelvic Fracture APC 2

 

APC 3 - complete SIJ disruption, nil vertical displacement

 

LC / Lateral Compression

 

LC1 - pubic rami + sacral compression same side

 

Pelvic Lateral Compression Fracture LC1

 

LC2 - pubic rami + iliac wing fracture

 

Pelvic Fracture LC2

 

LC3 - pubic rami + contralateral open book

 

Vertical Shear

 

Through SIJ or sometimes iliac wing / sacrum

 

Vertical Shear Sacral Fracture

 

CM / combined mechanism

 

Tile Classification

 

Type A: Stable (posterior arch intact)

 

A1: Avulsion injury
A2: Iliac-wing or anterior-arch fracture due to a direct blow
A3: Transverse sacrococcygeal fracture

 

Type B: Partially stable (incomplete disruption of posterior arch)

 

B1:  Open-book injury (external rotation)
B2:  Lateral-compression injury (internal rotation)
B2-1: Ipsilateral anterior and posterior injuries
B2-2: Contralateral (bucket-handle) injuries
B3:  Bilateral

 

Type C: Unstable (complete disruption of posterior arch)

 

C1: Unilateral
C1-1: Iliac fracture
C1-2: Sacroiliac fracture-dislocation
C1-3: Sacral fracture
C2: Bilateral, with one side type B, one side type C
C3: Bilateral

 

Open book injuries

 

Definition

- external rotation force

- no vertical displacement

 

Stages

 

Stage I - symphysis open < 2.5cm

Stage II - symphysis open > 2.5cm

Stage III - >2.5cm with peroneal wound

 

Is continuum with increasing external rotation force

- < 2.5cm posterior SIJ ligaments intact (like pregnancy)

- as progresses further the anterior SIJ ligaments rupture

- eventually posterior complex can be incompetent and have vertically unstable pelvis

- essentially have hemi-pelvectomy

 

Lateral compression

 

Mechanism

- IR force applied to ileum or more commonly to greater trochanter

- as pelvis is compressed risk of pelvic viscera injury especially bladder is great

- with increasing IR posterior structures may yield

- usually anterior sacroiliac crush is so stable that reduction is difficult

 

LC1

- ipsilateral

- superior and inferior rami fractured or

- superior ramus fracture with symphysis disrupted or

- locked symphysis

 

LC3

- bucket Handle

- contra-lateral ER / open book

- usually direct blow to pelvis

- fractured pelvis rotates like a bucket handle

- leads to LLD

- to reduce LLD need rotatory moment rather than traction

 

Stability

 

Stable

 

2 Types

- APC 1 & 2

- lateral compression injury

 

Unstable

 

Instability in the vertical plane

- no integrity of posterior ligamentous complex

- disruption of sacrospinous / sacrotuberous and posterior SI ligaments

 

Radiographic signs of instability

- SIJ > 5mm in any plane

- posterior fracture displacement

- avulsion 5th lumbar transverse process

- avulsion ischial spine (SS ligament)

- avulsion lateral border sacrum (ST ligament)

 

Sacrospinous Ligament Avulsion

 

X-rays

 

Inlet view

- 40o caudal

- shows AP displacement of sacrum c.f. pelvis

- anterior and posterior sacral borders

- enables insertion of SI screws

 

Pelvis Inlet viewPelvis Inlet

 

Outlet view

- 40o cephalad

- vertical displacement of sacrum relative to ilium

- to check reduction of vertical shear in OT

- enables insertion of SI screws

 

Pelvis Outlet ViewPelvis Outlet

 

CT scan

 

Better defines posterior injury

 

 

Management Acute

EMST / ATLS PrinciplesPelvic Fracture APC

 

Usually polytrauma

- 10% mortality

 

Aims

1. Volume replacement

2. Reduce pelvic ring

3. Stop exsanguination

- external stabilisation / surgery / embolisation

 

Associated Local Injuries

 

Arterial bleeders

- internal pudendal most common

- iliolumbar / SGA / IGA / lateral sacral / internal iliac

 

Retroperitoneal veins / bone bleeding

- 85% of bleeding

 

Compound injury

- urethra, vagina, rectum, peroneum

- need diverting colostomy prior to any anterior approach

- retrograde urethrogram for blood at meatus +/- retropubic catheter

- triple antibiotics (penicillin / gentamicin / metronidazole)

 

Pelvic Fracture Retrograde Urethrogram Normal

 

Neurological Damage

- L5/S1 most common

- L2 - S4 possible

 

Depends on location of sacral fracture and displacement

1.  Lateral to foramen - 6%

2.  Through foramen - 28%

3.  Medial to foramen - 57%

 

Sacral Fracture Transforaminal

 

Morel - Lavalle Lesion

- skin degloving

- high risk of contamination

- don't place incisions through this region

- needs debridement prior to definitive surgery

 

Intra-abdominal bleeding

- 32%

 

Management of bleeding / Liverpool Protocol / NSW Institute of Trauma

 

Options

- external fracture stabilisation

- embolisation

- surgical control

 

Basics

 

Embolisation 

- good for small arterial bleeders

- not haemodynamically compromised patient with massive bleeding

- unable to embolise large vessels and patient will die whilst attempting technique

 

Direct surgical control 

- rarely indicated and seldom successful

- main indications for open surgery are the open pelvic fracture and

- massive vessel injury leading to a patient in extremis from hypovolaemic shock

 

If patient is in extremis 

- i.e. BP < 60mmHg with no response to fluid management

- thoracic and abdominal bleeding ruled out

- blood loss is retroperitoneal

- need immediate laparotomy and cross clamping of aorta to buy time / allow haemostasis and vessel repair

 

Management with angiography services available

 

1.  Small allquots fluid (100-200 mls) to maintain SBP 80 -90 mm Hg +

stabilise pelvis with non invasive device

 

2.  Abdominal fast scan

 

A.  Negative

- immediate interventional angiography

- if becomes stable, ICU, manage pelvic fracture

- if unstable, repeat fast scan

- if positive, OT

- if negative, repeat angiogram

 

B.  Positive

- laparotomy

- external fixation

- remain unstable, immediate interventional angiogram

 

Mx without angiography services available

 

1.  Manage initially as above

 

2.  Abdominal fast scan

 

A.  Negative or unknown

- if SBP < 70 mm Hg

- OT for surgical control of bleeding and pelvic packing

- await retrieval for interventional angiography

 

B.  Positive

- OT for laparotomy and external fixation

- await retrieval for interventional angiography if continues unstable

 

Provisional Stabilisation

 

Pelvic binder

- simple, easy to use

- adequately reduces pelvic space

 

C clamp

 

Enables posterior control

- contra-indicated in iliac wing fracture

- in sacral comminution can over compress

 

Entry point of steinmann pins

- intersection of 2 lines

- line parallel with femur

- line back from ASIS

 

Complications

- too anterior, perforate ilium, organ damage

- too posterior, enter greater sciatic notch with nerve and vessel damage

 

External Fixation

 

Decreases pelvic volume

- indicated in open book and unstable pelvis

- rarely required for lateral compression fractures

- simple 4 or 6 pin frame in iliac crest

- pins at 45o to each other

- rarely definitive as has nursing issues

 

Outomes

 

Mortality

 

Dalal et al J Trauma 1989

- review of 345 patients with relation to mortality

- brain injury compounded by shock major cause in LC

- shock, sepsis and ARDS in APC due to major abdominal trauma

 

Open fractures

 

Dente et al Am J Surg 2005

- 44 open pelvic fractures

- mortality 45% at average day 17

- concurrent intra-abdominal injury 89% mortality

- vertical shear fractures universally fatal

- pelvic sepsis 60% mortality

 

Angiogram / Embolisation

 

Miller et al J Trauma 2003

- 28 patients hemodynamically unstable pelvic fractures

- classified as non responders if BP < 90 after 2 units blood

- 26 had angiography, 73% had an arterial bleeder embolised

- recommended angio as first line treatment in non responders

 

Pelvic Packing

 

Cothren et al J Trauma 2007

- 28 patients hemodynamically unstable from pelvic fractures

- had external fixation and pelvic packing

- no deaths from acute bleeding

 

Fast scan

 

Fuchholtz et al J Trauma 2004

- 31 patients with unstable pelvic fractures and free fluid on FAST

- all but 1 had intra-abdominal pathology requiring surgery

- FAST negative in 49 patients, 3 of whom went on to require laparotomy

 

 

 

Management Definitive

APC compression

 

Indications

 

Non Operative

- < 2.5 cm displacement

- indicates SS and ST intact

- nil posterior opening

 

Operative

 

1.  > 2.5 cm

- single anterior plate through Pfannelstiel incision

 

2.  Posterior SIJ disruption

- reduction and posterior stabilisation

- usually with SI screws

- if comminuted may need posterior plating

- anterior plate

 

Pelvic APC ORIF 1Pelvic APC ORIF 2Pelvis APC ORIF 3

 

Pfannenstiel approach / Plating Pubic Symphysis

 

Technique

 

Set up

- supine on radiolucent table

- IDC to decompress bladder

 

Incision 2cm above pubis

- through fat and fascia

- avoid detaching rectus

- usually part torn off already

 

Reduction techniques

- during the reduction care must be taken to avoid trapping bladder or urethra in the symphysis when closing the clamp

 

A.  Assistant may apply pressure over each iliac crest or an external fixator can be applied

B.  Large pointed reduction clamp can be placed onto each pubic tubercle or through holes drilled in the bone

C.  Expose the medial obturator foramen and application of pelvic reduction forceps thru the medial aspect of the foramen

 

Superiorly applied plate

- pelvic reconstruction plate

 

Pelvis Pubic Symphysis Plate 1Pelvis Pubic Symphysis Plate 2Pelvis Pubic Symphysis Plate 3

 

Iliosacral Screws

 

Contra-indication

 

Posterior sacral comminution / foraminal fracture

- may be better with anterior / posterior plating

 

Technique
 

Radiolucent table with II

- 45o cephalad and caudal

- inlet and outlet view

 

Must reduce joint / fracture initially

- reduce vertically with traction on limb / outlet view

- reduce AP usually via compression / inlet view

 

Guide wire insertion

 

Anatomic safe zone

- between S1 foramen and sup ala on outlet view (outlet view)

- between neural canal and anterior body  (inlet view)

 

Pelvis Sacroiliac Screws InletPelvis Sacroiliac Outlet

 

Insert 6.5 mm cannulated screw with compression

 

Dangers

 

S1 nerve root inferiorly

Vessels and ureter anteriorly

Cauda equina posteriorly

L5 nerve root superiorly

 

Post operative

 

Check screw position with CT

NWB 6/52

 

Complications

 

S1 nerve root injury

SI osteoarthritis

Malunion

Failure of fixation

 

Results

 

Routt et al J Orthop Trauma 1997

- 177 patients treated with percutaneous SI screws

- open reduction required if unable to obtain closed reduction < 1cm widening

- inadequate II due to obesity or abdominal contrast in 18 patients

- 5 misplaced screws due to surgeon error with 1 transient L5 neuropraxia

- fixation failure in 7 patients usually due to head injury / non compliance / delayed union

- non union in 2 patients

 

Sacro-iliac Plating

 

A.  Anterior

 

Pelvic Anterior Sacroiliac Plate 1Pelvis Anterior Sacroiliac Plate 2Pelvis Anterior Sacroiliac Plate 3

 

Indications

- combination with anterior approaches

- anterior plating of pubic symphysis

- anterior approach acetabulum required

 

Technique

- use lateral window of ilioinguinal or stoppa approach

- L5 nerve root at risk

 

B.  Posterior

 

Indication

- comminuted posterior sacral injury

 

Technique

- patient prone

- vertical incision 1 cm lateral to PSIS

- from crest to sciatic notch

- incise and reflect G maximus

- apply transverse plate

- soft tissue can be a problem

 

Lateral Compression Fracture

 

Indications for ORIF

 

LLD  2.5 cm

 

Significant internal rotation

- risk of impingement

- especially young female / interfere with birth passage

 

Lateral Compression ORIF

 

Options

 

External rotation external fixation

 

Vertically Unstable Fractures

 

Management

 

Intial

 

Femoral steiman pin + 20lb weight to reduce vertical displacement

External fixation to pelvis

 

Definitive

 

Anterior plate

 

Posterior stabilisation

- posterior SI screws / anterior or posterior plate

 

Results

 

Griffin et al J Orthop Trauma 2006

- retrospective review of 62 patients treated with SI screws

- 4 failures in patients with vertical sacral fractures

- recommended plate fixation in this group

 

Non Ring Pelvic Fractures

Psoas Avulsion

 

Psoas Avulsion

 

Ileum Fracture

 

Ileum Fracture

 

ASIS Avulsion

 

Sartorius

 

AIIS Avulsion

 

Rectus femoris

 

Ischial Tuberosity avulsion

 

Hamstrings

- see article on hamstring avulsion

 

 

 

 

Proximal Hamstring Tear

Epidemiology

 

Adolescent apophyseal avulsion

- treat non operatively

- unless displaced > 2 cm

 

Adult

- soft tissue avulsion

 

Aetiology

 

Usually associated with sporting activities

- skiing

- water skiing

 

Violent contraction

- knee extended

- hip flexing

 

Anatomy

 

Biceps / Semimembranosus / Semitendinosus all attach here

 

Symptoms

 

Pain

Unble to run

 

Chronic tears

- may have some neuralgia symptoms

 

Signs

 

Large haematoma / bruise

Palpable defect

Distal retraction of muscle into thigh with contraction

 

Proximal Hamstring Rupture Bruise

 

Xray

 

May see bony avulsion

 

MRI

 

Proximal Hamstring Avulsion MRI CoronalProximal Hamstring Avulsion MRI Axial

 

Management

 

Non operative

 

Results

 

Harris et al Int J Sports Med 2011

- systematic review

- better subjective outcome / return to sport / hamstring strength with repair c.f. non operative

- better outcomes with acute (< 4 weeks) than chronic repair

 

Operative

 

Surgical Technique

 

Patient prone

- knee flexed over sterile gowns

 

Incision

- longitudinal incision centred on ischial tuberosity

- starting at gluteal crease

 

Superficial dissection

- divide fascia in line with incision

- preserve posterior femoral cutaneous nerve

- identify and elevate inferior edge of gluteus maximus

 

Deep dissection

- identify and preserve sciatic nerve (lateral to hamstring)

- identify hamstring tendon

- repair with multiple large suture anchors

- ensure no kinking of sciatic nerve at end of case

 

Hamstring Repair Sciatic NerveHamstring Repair Sciatic Nerve 2

 

Proximal Hamstring Rupture Post Op

 

Post op

- splint with knee flexed

- prevent hip flexion

- crutches

 

Proximal Hamstring Brace

 

Complications

 

Residual weakness (60 - 90% other side)

Neuralgia

 

Chronic > 4 weeks

 

Indication

- patient complains they cannot run

 

More difficult

- careful dissection of sciatic nerve from adhesions

- release hamstring tendon

 

Augment options

- autologous ITB

- allograft

 

Technique

 

Release hamstring

- identify nerve, and use vessiloops

- avoid denervating the muscle, must preserve the nerve branches

- identify the ischial tuberosity

- see if hamstring will reach, sometimes will, but cannot repair under tension

 

Sciatic Nerve ReleaseChronic Hamstring Tear 1Chronic Hamstring Tear 2Chronic Hamstring Tear 3

 

Prepare allograft

- tendo achilles

- 9 x 20 mm bone block

- drill to 10 x 25 mm tunnel using ACL instruments

- ensure that beath pin does not advance

- secure with 7 x 20 mm screw, bone typically very strong

 

Drill hole ischial tuberositySecure allograft bone plug with screwSecure allograft bone plug with screw 2

 

Pulvetaft weave tendon through muscle stump

- through the strongest, thickest part of the stump

- high strength suture tendon to tendon

- can pass again

- tension leg, must be able to reach full extension

- brace for 6 weeks, no sport for 6 months

 

Hamstring Allograft ReconstructionHamstring Allograft ReconstructionPost Proximal Hamstring Reconstruction

 

Results

 

Sarimo et al Am J Sports Med 2008 36

- 41 patients

- 5 chronic requiring achilles allograft

- 96% would have it done again, 80% return to sport

- no difference in strength between acute and chronic

 

Cohen Am J Sports Med 2012

- 52 patients

- 40 acute, 12 chronic

- 98% satisfied

- minimal difference in outcome between acute and chronic

 

Murray KSSTA 2009

- achilles allograft recon of chronic (6 months) rupture

- good outcome

Snapping Hip

Causes

 

Most common

- fascia lata on greater trochanter

- iliopsoas on lesser trochanter

 

1.  Intra-articular structures

- labrum

- ligamentum Teres

- loose bodies

- synovial chondromatosis

- osteochondoma

 

2.  Extra-articular structures

- fascia lata on greater trochanter (common) 

- iliopsoas on lesser trochanter / iliopectineal eminence 

- long head biceps femoris over ischial tuberosity

- iliofemoral ligament over femoral head

 

Iliotibial Band over GT

 

Symptoms

 

Usually painless

Can often be produced voluntarily

 

Examination

 

Hip flexion and internal rotation causes readily palpable snapping sensation

- tight iliotibial band subluxates over the greater trochanter

 

Management

 

Majority of patients no treatment required

- rest

- iliotibial band stretching exercises

- NSAIDS +/- local corticosteroid injections

 

Surgery

- rare persistent cases 

- elliptical resection of the iliotibial band over the greater trochanter + greater trochanteric bursectomy 

 

Iliopsoas Tendon

 

Symptoms

- snapping sensation felt in the groin as the hip is extended from a flexed position

- palpated as the supine patient extends the hip from a position of flexion / abduction & external rotation

 

Management

 

Non operative as above

 

Surgery

- resistant cases

- psoas lengthening

- resection prominence of lesser trochanter

- psoas division (can be done arthroscopically)

 

 

 

Sportsman's Hernia

Definition

 

Groin pain in athletes

- secondary to tear in external oblique fascia

 

Epidemiology

 

Sports with aggressive adduction

- hockey / soccer

 

Pathology

 

Tears in external oblique fascia

- tend to be central

- around spermatic cord and ilioinguinal nerve

- pain may be from nerve entrapment

 

DDx

 

Adductor Longus Tear

Osteitis Pubis

 

Symphysis Pubitis

 

Hip pathology

 

NHx

 

Adductor longus tears

- get better with time

- rarely need surgery

- pain stays below goin

 

Sports Hernia

- may have nerve / ilioinguinal symptoms

- above groin

- often get worse

 

Examination

 

Adductor longus tears

- tender over tendon

- pain / weakness on resisted adduction

 

Sports hernia

- tender over inguinal ring

- may have palpable dilatation of external inguinal ring

- pain with resisted sit up

- pain with resisted leg flexion

 

Dynamic ultrasound

 

May be useful in very experienced hands

 

MRI

 

Can be difficult to see

Is often a clinical diagnosis

 

Management

 

Non Operative

 

Rest

Exclude other diagnosis

 

Operative

 

Hernia repair

 

Technique

- expose external oblique fascia

- identify and protect spermatic cord

- identify tears / pathology

- release ilioinguinal nerve

- repair primarily or with gortex mesh

 

Ilioinguinal nerve

- some surgeons cut the nerve

- risk neuroma

- suprapubic numbness only

 

Can combine with adductor tenotomy

 

 

 

 

 

THR Australian Joint Registry

 

2009 / Revision Rates 8 year

 

Prosthesis Type All Diagnosis 7 year

 

Unipolar Monoblock 6.8%

Unipolar Modular 6.8%

Bipolar Hemi 4.2%

 

Cemented THR 3.8%

Cementless THR 4.4%

Hybrid THR 3.9%

 

Total Resurfacing 5.4%

Thrust Plate 3.0%

 

Revision for OA 8 year

 

Conventional THR  4.0%

Total Resurfacing   5.3%

 

Partial Hip Replacement

Cemented better than cementless in all categories

 

Hemiarthroplasty

 

1.  > 85 

- unipolar monoblock 3.4% 7 years

- unipolar modular 2.1% 5 years

- bipolar 2.9% 7 year

 

2.  75-84

- unipolar monoblock 8.5% 9 years

- unipolar modular 5.5% 7 years

- bipolar 3.5% 7 years

 

3.  < 75 

- unipolar monoblock 17.5% 7 year

- unipolar modular 13.4% 7 year

- bipolar 6% 7 year revision rate

 

Primary Conventional THR

 

By Age

 

< 55   4.9%

55-64  4.6%

65-74  3.6%

>75     3.7%

 

By Gender

 

Female  3.8%

Male     4.3%

 

By Fixation

 

Cemented    3.9%

Cementless  4.4%

Hybrid         3.4%

 

By Age & Fixation

 

< 55      hybrid (4.6) < cementless (4.8)

55-64     hybrid (3.6) < cementless (4.7)  < cemented (6.1)

65-74     hybrid (3.2) < cemented (3.8) < cementless (3.9)

> 75      cemented (3.1) < Hybrid (3.3) < cementless (4.2)

 

By Diagnosis

 

AVN 5.1%

DDH 3.5%

NOF  5.2%

OA    4.0%

RA    5.4%

 

By Bearing Surface

 

Ceramic / Ceramic  3.9%

Metal / Poly             3.2%

Ceramic / Poly         4.1%

Metal / Metal           7.7% (Head sizes > 28mm)

 

By Head Size

 

Ceramic / Ceramic

</= 28          4.6%

> 28              3.5%

 

Metal / Poly

>/= 28          3.9%

> 28              3.0%

 

By Cemented THR

 

MS30/Low Profile cup     1.0%

Exeter/Exeter                3.2%

Exeter / Contemporary   6.6%

Spectron / Reflection      6.9%

 

By Cementless THR

 

Securefit Plus / Trident  2.8%

Mallory Head                5.5%

Synergy/Reflection        3.8%

ABGII/ABGII                 5.6%

 

By Hybrid THR

 

Definition / Vitalock        1.5

Exeter/Vitalock              3.6%

Spectron/Reflection        5.4%

 

Identified as higher than expected

 

Corail / ASR 

 

Hip Resurfacing

 

13 300 procedures

 

Best outcome

- male < 65 with OA

- able to get > 50 mm head size

- 3.9% 9 year

 

Revision rate

 

Cumulative revision rate

- 7.2% 9 years for OA

 

Birmingham Resurfacing

- 6.2% 9 year

 

Reasons for revision

- fracture 36%

- loosening 33%

- metal sensitivity 7%

 

Revision by diagnosis 7 years

- OA 5.8%

- DDH 14%

- AVN 6%

 

Revision by prosthesis

- BHR 96.5% 5 year

 

Revision by age 7 years

- < 55     5.6%

- 55 - 64  5.8%

- > 65     7.3%

 

Revision by sex 7 years

- male 4.5%

- female 9.3%

 

Revision by head size 7 years

- < 44mm:    13.8%

- 45 - 49mm: 8.8%

- 50 - 54mm: 3.7%

- > 55mm:     2.2%

 

Revision

 

Type

 

Femoral only 21.5%

Acetabular only 37.1%

Combined         35.8%

 

Reason

 

Loosening 45.7%

Dislocation           14.8%

Lysis                    10.1%

Fracture                9.2%

Infection               9.1%

Wear Acetabulum   3.3%

Pain                      2.1%

 

Re-revision Rate

 

Minor (head, liner)   19.4% 5 year

Major Partial            14.1% 5 year

Major Total               8.2%   3 year

THR Complications

DVT Prevention

 

ANZ Working Party on the Management and Prevention of Venous Thromboembolism 2007

 

Note

 

Top 6 conditions associated with DVT

- stroke

- THR

- multi trauma

- TKR

- hip fracture

- spinal cord injury

 

Not one of the 12 doctors was an orthopaedic surgeon

 

Agents

 

Heparin / LMWH / fondaparinux

- confirmed effectiveness

 

Aspirin

- not recommended

- at best weak effect in some people

 

Warfarin

- a role in some high risk surgical patient

- requires monitoring

 

Timing

 

Inconclusive in many areas

 

Recommend 28 - 35 days in

- hip fracture

- THR

 

Epidural Catheter

 

No anticoagulant within 12 hours of inserting / 6 hours of withdrawing epidural catheter

 

Mechanical compression

 

Graduated compression / intermittent pneumatic compression / foot pumps have all been shown to work

 

Recommended to combine with chemoprophylaxis

 

Use unless contra-indicated

- severe peripheral arterial disease or neuropathy

 

Specific Recommendations

 

THR / Hip Fracture

 

Enoxaparin 40 mg / day commencing 6 - 8 hours post op for 28 - 35 days 

 

TKR / Multi-trauma / Prior VTE / Cancer

 

Enoxaparin 40 mg / day commencing 6 - 8 hours post op

Post op for 5 - 10 days

 

Major Surgery (any surgery > 45 minutes)

 

Enoxaparin 20 mg / day commencing 6 - 8 hours post op for 5 - 10 days

 

High risk patients

 

Oestrogen therapy

Pregnancy

Obesity

Strong FHx VTE

 

Contraindications to chemoprophylaxis

 

Active bleeding

High risk bleeding

- hemophilia

- platelets < 50

- history GI bleeding

Severe hepatic disease (INR < 1.3)

Allergic to heparin

High risk of falls

Palliative Management

 

 

 

Dislocation

IncidenceTHR Dislocation

 

2-3% of cases 

- doubles with infrequent operator

- second most common reason for revision after loosening

 

Australian Joint Registry

- dislocation accounts for 14.8% of revisions

 

Positions

 

Posterior dislocation

- hip flexed, adducted, IR

- 80%

- usually getting out of chair

 

Anterior dislocation

- hip extended, adducted, ER

 

THR Anterior Dislocation

 

Timing

 

Early < 6/ 52

- majority of single dislocations

- usually excessive hip position by patient

- before adequate muscle control & soft tissue healing

- after six weeks strong pseudocapsule forms about hip

- adds to stability +++

 

Chance of recurrence 40%

 

Late > 6 weeks

- represents majority of recurrent dislocations

- sually due to increase in ROM & activity

- manifests unrecognised impingement / malposition

 

Chance of recurrence 60%

 

Factors

 

Surgeon factors

- experience

- approach

- component position

- component design

- soft tissue balance

- impingment

 

Patient factors

- soft tissue

- cognitive disorders

- NM disorders

- NOF fracture

- revision

 

Surgeon Factors

 

1.  Surgeon Experience

- < 30 THR per year

- 2 x dislocation rate

 

2.  Approach

 

A.  Increased with posterior approach

- common in early papers

- reduced with short ER repair / use of large heads / component position

- now equivalent rates to anterolateral

 

B.  Transtrochanteric

- increased with trochanteric non union x6

 

3.  Component position

 

Dislocated THR Open Acetabulum

 

A.  Acetabular safe zones

- abduction 40 +/- 10o

- anteversion 15 - 30o

 

B.  Excessive femoral anteversion

- especially when combined with excessive acetabular anteversion

- predisposes to anterior dislocation

 

C.  Ranawat concept of combined anteversion

- acetabular + femoral anterversion

- 25 - 35o for men

- 35 - 45o for women

 

D.  May wish to increase anteversion in posterior approach and reduce it in the anterior approach

 

4.  Component design

 

A.  Increased head size

 

THR Big Head Dislocation

 

Increased size increases head-neck ratio

- reduces impingement / increases arc of motion

 

Increased jump distance

- seated deeper in acetabulum

- decreases jump distance

- greater translation before dislocation

 

B.  Liner profile

- posteriorly elevated profiles

- i.e. neutral liners v 10o elevated rim liners

- theoretically more stable

- reduces dislocation rates early, but not late

- can cause impingement in extension and ER

- this may lead to dislocation and increased wear

- can put hood in variety of positions

- usually postero-superior

 

5.  Soft tissue tension

 

A.  Restore LLD and offset

- reduced offset associated with increased dislocation

- reduces ST tension

- increases risk of impingement

 

B.  Dislocations reduced with careful capsular and soft tissue repair

- reduces dislocation rate in posterior approach

 

6.  Impingement

- when two non articular surfaces come into contact during joint ROM

- decrease by increasing head neck ratio

- may be liner / osteophyte / excessive capsule

- always put hip through ROM

- ensure in full extension and ER, no posterior impingment

- ensure in flexion 90o and IR, no anterior impingment

 

Patient Factors

 

1.  Soft tissue function

- previous hip surgery 

- revision THR

- weak abductors

 

2.  Cognitive disorders

- dementia / delerium

- alcoholism

 

3.  NM disorders

 

4.  Women

 

5.  Post THR for Neck of Femur fracture

- no stabilising capsular hypertrophy / fibrosis seen in OA

 

6.  Revision

- dislocation rates higher in revision setting

 

Prevention

 

Pre-operative education

- avoid dislocation in first 6 weeks

 

Template

- restore offset and leg length

 

Approach

 

Posterior approach

- careful short ER repair

 

Trochanteric osteotomy

- large flat surface

- strong repair

- protected WB /52

 

Component positioning

 

A. Extrapelvic Landmarks

- careful patient positioning

- patient stable

- ASIS perpendicular to floor

- use guides on acetabular insertion jigs

 

B.  Intrapelvic Landmarks

- transverse acetabular ligament

- anterior and posterior acetabular walls if no osteophytes

 

Component design

- liner lip posterosuperior

 

Prevent impingement

- remove wall osteophytes

- restore offset

- anterior capsule can cause impingement

- avoid excess cement

 

Large head neck ratio

 

Trial reduction

- flex to 90o, IR 45o, adduct 20o

- full extension, ER 45o

- ensure stability

- restore offset

- check LLD

 

Post operative

- avoid extremes of position

- abduction pillow

- knee immobiliser in confused patients / limits hip flexion

- post-op education

- no driving, high chairs, low cars 6 weeks

- no crossing legs ever

 

Management

 

Early 

- MUA 

- re-educated

- mobilise as tolerated

 

Late

 

1st episode 

- treat with reduction

 

Recurrence 

- treat with abduction brace 

- 20° flexion / Abudction / ER

- for 6/52

 

Repeated 

- revision

 

X-ray evaluation

 

A.  Component malposition

 

1.  Acetabular Abduction

 

Easy to assess on AP

 

THR Acetabulum Closed < 45 degreesTHR Acetabulum open > 45 degreesTHR Dislocation Abducted Acetabular Component

 

2.  Acetabular Anteversion

 

Much more difficult to assess

- compare ellipse of acetabulum on AP pelvis and AP hip

 

Concept

- AP pelvis the beam is centred over the pelvis

- AP hip the beam is centred over the hip

 

If cup anteverted

- looks flat on AP pelvis

- looks elliptical on AP hip

 

If cup retroverted

- looks elliptical on AP pelvis

- looks flat on AP hip

 

THR AP Pelvis Elliptical CUpTHR AP Hip Straight Cup

 

B.  Other

 

Eccentric liner wear

- draw lines on paper, compare each side

- thickness not equal both sides with wear

 

THR Poly Wear

 

Loosening

 

Insufficient offset

 

Surgical Revision

 

Need to decide cause of problem

- preoperative and intraoperative

- malposition / impingement / soft tissue

- have options available to address each problem

 

Initial

 

1.  Impingement 

- removal of osteophytes or cement

- exchange components to improve head neck ratio

- may need to adjust component malposition

 

2.  Malposition 

- assess stem + cup on CT

 

Options

- change for Augmented polyethylene lining (if uncemented cup)

- revise component positioning

- larger head technology

 

3.  Incorrect tissue tension 

- longer neck / correct offset

 

4.  Worn liner

- exchange liner

 

5. Abductor insufficiency 

- trochanteric advancement

- increase femoral offset (modular head, lateralised liner)

 

Salvage

 

1.  Constrained cups

 

THR Constrained CUp

 

Concept

- an acetabular component that uses a mechanism to restrain the femoral head within the cup

- can be implanted denovo or cemented into well fixed cup

- usually has a metal locking ring

 

Indication

- deficient soft tissues

- paralysed abductors

- GT non union

 

Varieties

A.  Cup and monopolar liner with locking ring

B.  Bipolar constrained liner with locking ring

 

Problems

 

A. A constrained cup may still dislocate

- usually require surgery to relocate / require revision

 

THR Dislocation Constrained Liner 1THR Dislocation Constrained Liner 2

 

B. Inhibit ROM and transmit significant forces, which may contribute to early loosening

 

2.  Failure or Unreliable patients 

 

Options

- bipolar hemiarthroplasty

- girdlestones

 

 

Heterotopic Ossification

DefinitionHO Brooker 4

 

Extraskeletal bone formation in periarticular tissues 

- HA crystals within osteoid matrix

 

Different to calcification 

- osteoid matrix laid down

 

Types

 

1.  Myositis Ossificans

- post traumatic

 

2.  Heterotopic Ossification / associated with TJR

 

3.  Neoplastic Ossification

 

Epidemiology

 

Occurs 50-70% THR's

- significant in 20%

- clinically significant in 1%

 

More common in men x 2

 

Risk factors

 

High 

- previous hip / other hip HO

- incidence is 80%

 

Moderate

- hypertrophic OA

- active Ankylosing Spondylitis

- hyperostosis

- DISH 

- active Paget's 

- fracture (acetabular trauma, pre or intra operative)

 

Low

- THR

- posterior approach < Hardinge < transtrochanteric

 

Pathology

 

Similar cascade to fracture healing

- unknown trigger

- undifferentiated mesenchymal cells differentiate in osteoblasts

- occurs within first few days

- produce osteoid

- mineralised to bone (mature lamellar bone)

 

Two Precursor cells about the Hip / Friedenstein

 

1.  Determined Osteogenic Progenitor Cells

- from bone marrow

- develop into osteoblasts with inflammation

 

2.  Inducible Osteogenic Progenitor Cells

- need BMP to develop into osteoblasts

 

Brooker Classification

 

Only Type IV interferes with function

 

Type I:  Isolated islands of bone

 

Heterotropic Bone Brooker 1

 

Type II:  Bony spurs from pelves and proximal femur, gap > 1 cm

 

Heterotropic Bone Brooker 2

 

Type III:  Gap < 1 cm

 

Heterotropic Bone Brooker 3

 

Type IV:  Apparent ankylosis

 

Heterotropic Bone Brooker 4

 

Clinical Features

 

Usually none

- pain usually as it matures

- decreased ROM

- dislocation 2° impingement (rare due to loss of ROM)

- nerve irritation

- trochanteric bursitis

- hip can appear red, swollen and tender

 

X-ray

 

New bone in peri prosthetic soft tissues

- visible by 3-6/52

- extent determined by 3/12

 

Maturation continues for 12-18/12 

 

Bone Scan

 

Increased uptake = continued activity

- remain increased for 12/12

 

Bloods

 

Rise in serum alkaline phosphatase post surgery

- associated with HO

 

Management

 

1.  Prevention 

 

Identify at patients risk preoperatively

- Ankylosing Spondylitis / Pagets / Previous HO / DISH

 

A.  Surgical Technique

 

Gentle handling of tissues

- avoid muscle stripping

- lavage tissues

- drain wound

 

B.  NSAID

 

Indomethacin 50 mg bd for 1 week

- significant reduction in risk of HO

- 7 days as effective as 14 days

- as effective as postoperative radiation

 

Risk of GIT side-effects ~ 20%

- interaction with anticoagulants

- double risk of significant bleeding with DVT prophylaxis

 

Results

 

Knelles JBJS 1997

- 685 Primary THR

- 50mg bd Indocid for 1 week

- as effective as 1 x 7 Gy Post-op

 

C.  DXRT

 

For very high risk patients

- previous HO / indocid contraindicated because of PUD

- post surgical excision of HO

 

Dosing

- 700 Rad / 7 Gy < day 5

- 800 Rad 6h pre-op prevents HO

 

Side effects

1.  Delay incorporation of bone graft / union of trochanter

2.  May delay porous ingrowth with uncemented components

3.  Can make patient nauseous

4.  Nil evidence wound problems (shielded, low dose)

5.  Risk of malignancy - nil evidence at this low dose

 

D. Biphosphonates

 

Delay calcification and delay Xray appearance of bone 

- doesn't prevent osteoid formation

- calcification occurs once drug stopped

- no longer used

 

2.  Surgical Excision

 

Indications

 

Significant symptoms / reduced ROM & > Brooker III

- revision of prosthesis

 

Timing

 

Usually 12-18 / 12 post-operatively

- mature appearance on XR

- cold Bone Scan

- serum ALP normal

 

Prophylaxis

 

Radiotherapy post oeratively as high risk 

 

Results

 

Usually increased ROM

- unreliable effect on pain

- bone often reforms

 

Case

 

THR HO Brooker 4THR HO Brooker 4 Poster ExcisionTHR Post HO Excision Dislocation

 

 

 

 

 

 

 

 

Infected THR

Risk factors

 

Patient 

 

Advanced age

Immunosuppression - steroids / Rheumatoid / DM

Malnutrition - Lymphocyte count / Transferrin / Albumin

Vascular disease

Obesity

Poor skin i.e. psoriasis

Previous infection in joint

Infection elsewhere - i.e. UTi

Prolonged hospital admission

Revision surgery

 

Operative Factors

 

Preoperative

- preoperative wash

- preoperative shave

- admission day of surgery to clean ward

- groin, nasal, axilla swabs clear

- clear urine (MCS preop)

- no skin breaks

 

Operative Period

- laminar flow

- minimal theatre traffic

- IV Abx on induction

- shields

- alcoholic prep

- prep drapes

- short procedure duration

- care of soft tissues

- ABx cement

- wound closure / drains / hemostasis

 

Postoperative Period

- wound haematoma & drainage

- skin necrosis

- post operative ABx

- management remote infections i.e. UTI

- care with dental procedures

 

Incidence

 

Current rate 0.27 - 2 % 

 

Increased risk with high-risk patients (2%)

- immuno-compromised

- recurrent bacteraemia

- revision > 2%

- RA

 

Microbiology

 

S. epidermis most common with S. aureus second

- together make up two thirds of all infections

 

MRSA increasing in prevalence

Also vancomycin resistant S. aureus

 

Also

- streptococcus

- S. capitus

- pseudomonas

- coliforms

- anaerobes

- mixed 1/4

 

Symptoms

 

Usually worsening hip pain

- often minimal constitutional symptoms

 

X-ray

 

Progressive / rapid lysis / bone loss

May be normal appearing xray

 

Infected THR progressive bone loss and lysis

 

Investigations

 

For full details, please see Investigation of Pain in THR Complications section

 

Ultrasound

 

Fluid collection about hip

 

Bloods

 

CRP > 10 and ESR > 30 very suspicious

 

Bone scan

 

Reveal increased uptake about both components

- blood flow, blood pool and delayed uptake phases

- more than 12/12 post implantation

 

Specificity increased by WC scan

 

Aspiration

 

Under II control

- off antibiotics

- confirm infection

 

THR Aspiration

 

Pathology

 

1.  Prosthesis in bone

- difficult for antibiotics to access

- poor blood supply

- similar to osteomyelitis

 

2.  Glycocalyx 

 

Bacteria have two forms

A.  Planktonic form 

- individual free floating cells

B.  Sessile form 

- exist within biofilm of glycocalyx

- 500x more resistant than planktonic form

 

Glycocalyx is a slime layer of polysaccharides produced by bacteria 

- protective barrier against antimicrobial and host defences

- helps bacteria to exist and survive on synthetic substances

- biofilm requires minimum time to form

- infection can be irradicated by Abx while still in planktonic phase but not once form biofilm

 

3.  Prosthesis Surface Properties

 

CO-Cr more susceptible to infection than titanium

- may be related to faster osseointegration by titanium

 

Polished surfaces less susceptible

- smaller surface area for bacteria to adhere

- shorter distance for host cell to travel

 

Classification Gustilo 1993

 

1.  Early post-operative

- < 1/12

- febrile patient

- red swollen discharging wound

 

2.  Late post-operative

- indolent (low virulent)

- > 1/12

 

Typically

- well patient

- healed wound

- worsening of pain

- never pain-free interval

 

3.  Acute haematogenous

- antecedent bacteraemia

- can occur several years after surgery

 

Typically

- well patient

- previously well functioning hip

- UTi or other source of infection

- hip now very painful

 

4. Positive intra-operative culture

- presumptive diagnosis aseptic loosening

- intra-operative m/c/s comes back positive (2 out of 5)

- treat with 6 weeks Abx -> success rate 90% 

 

Management

 

Goals

 

Eradicate infection

Relieve pain

Restore function

 

Options

 

1.  ABx suppression

2.  Debridement and prosthesis retention

3.  One stage revision

4.  Two stage revision

5.  Three stage revision

6.  Resection arthroplasty

 

1. Antibiotic Suppression

 

Indications

 

1.  Gustillo Type 4 

- 90% success

 

2.  Elderly and frail

 

Require

 

Known sensitive organism

Stable prosthesis

Tolerable oral Abx

 

Treatment

 

Indefinite

- 50% retention of prosthesis at 3 years 

 

2. Debridement with Retention THR

 

Indications

 

Time

- symptoms < 4/52

 

Stability

- well fixed prosthesis

 

Microbe

- known sensitive organism

 

Host

- Cierny A / B / C

 

Treatment

 

No Abx until

- swab and tissue for M/C/S

- or after positive blood culture

 

Operation

 

Excision of all necrotic and infected tissue

- ensure implant well fixed

- exchange liner (if uncemented)

- wash +++

- monofilament nylon sutures

- drain

 

IV Abx 6/52

 

Vanco / genta initially until swabs available

- ID consult

 

Results

 

1.  Early post-op infection in cemented well fixed THR

- success = 75% 

 

2.  Early post- op infection in uncemented 

- worse results

- due to lack of cement obstruction

- required 2 stage revision if no bone ingrowth

 

3.  Acute haematogenous

- only 50% success 

- often immunocompromised

 

4.  Chronic late

- poor results 

- window of opportunity lost

 

3. One-Stage Revision

 

Infected THR Pre One stage revisionInfected THR Post One Stage Revision

 

Concept

 

Controversial

- remove prosthesis, debride and replace at single sitting

- lower success rate than two stage

- usually indicated in older, more frail patient

- meticulous debridement critical

- treat infection like cancer

 

Indications

 

Timing

- late onset

 

Host

- healthy host

 

Microbe

- sensitive organisms (gm+)

 

Stability

- no sinuses / good wound

- adequate bone stock

 

Technique

 

Debridement all necrotic and infected tissue

- removal of implants and all cement

- aided by extended trochanteric osteotomy

- wash +++

- re-drape, new instruments

 

Reimplant cemented polished femur and all poly cup

- must use ABx PMMA

- already has tobramycin in it

- add powder form vancomycin 

- 2-3 gram in each packet of cement

- each vanco vial is 0.5g

- femur and acetabulum

 

Can implant poly liner from uncemented acetabulum only

- more ABx cement can be impregnated

- large head for stability

 

Post operative

- IV Ab's 6/52

 

Antibiotics must be

- thermostable (excludes tetracycline & chloramphenicol)

- powder form (not genta)

- low allergenic potential

- elute from the cement

- effective against the infecting organism

- Palacos better as higher surface porosity

 

Results

 

80% long term survival

 

4. Two-Stage Revision

 

Gold Standard

 

Indications

 

Chronic late

Acute haematogenous

 

Advantages

 

Improved success rate compared with single stage

- success 90% with ABx cement

- 2 opportunities for debridement

 

Disadvantages

 

1.  2 procedures required

- difficult for patient between stages

 

2.  Revision surgery more difficult

- scar formation 

- shortening

- distortion of anatomy

 

3.  Increased cost / Longer time

 

First stage

 

Complete debridement

- removal all implants and cement

- meticulous debridement necrotic an infected soft tissue

- insert spacer

 

A.  Ball of ABx Cement

 

Infected THR Cement Ball

 

Advantage

- leeches ABx

- maintain space for revison hip

 

Disadvantage

- very uncomfortable

- o mobility benefit to patient

- can cause bony erosion

 

B.  Abx cement in mould

 

Infected THR Cement Spacer Fracture

 

Disadvantage

- poor function

- fractures / breaks

- painful

- difficult to mobilise

- can cause further bone loss

 

C.  Company produced cement spacer

 

Prostalac

- metal spine

- can dislocate / cause bone loss / cause femur fracture

 

Infected THR Prostalac SpacerInfected THR Dislocated ProstalacProstalac Femur Fracture

 

D.  All poly liner and cemented stem

 

Infected THR Kiwi Hip Spacer

 

Concept of the "kiwi" hip

- +++ Abx cement

- cheap polished femur loosely cemented in

- uncemented poly liner to increase cement load in acetabulum

 

Advantage

- stable construct

- patient can mobilise

- no rush to revise

 

Disadvantage

- cost

 

E.  Antibiotic Coated Nail

 

Infected THR NailAntibiotic Coated Nail

 

Second Stage

 

Timing

- Abx minimum 6/52

- at least 2 - 4 weeks off ABx

- consider hip aspiration

- normal CRP / ESR

- intra-operative FFS at time of surgery

 

5. Three stage Revision

 

A.  Remove implants - 4-6/52 Abx

B.  Bone graft defects - 3-12/12

C.  Revise components when graft incorporated

 

6. Resection Arthroplasty (Girdlestone)

 

Described in 1928 for TB

 

Infected THR GIrdlestones

 

Indications

- medically unfit for further revision surgery

- refusal for further revision surgery

- sepsis control / virulent bug

- unrevisable due to bone loss

- unlikely to become mobile

 

Advantage

 

Effective control of infection (95%)

 

Disadvantage

 

Poor function

- pain

- limp

- require walking aid

- 5cm average LLD

- increased energy expenditure 250%

 

Leaves pateint with nearly useless pseudoarthrosis

- weight bearing almost impossible

- severe shortening

- consider only as last resort

 

Post operative

- used to recommend 6/52 traction

- makes no difference

 

7. Amputation

 

Technique

- hip disarticulation

 

Indications

 

Life-threatening infection

Severe loss of ST & bone stock

Vascular injury

 

Incidence

 

Performed in 0.1%

 

 

 

Intra-operative Fracture

THR Acetabular Fracture

 

Incidence

 

Increased incidence with press-fit component

- especially if under ream

 

Prevention

 

Don't under-ream >1mm

 

In osteopenic bone 

- line to line reaming

- i.e. ream to outer diameter of cup

 

This also avoids leaving gaps at floor 

- very common if under-ream by 2mm

 

Management Intra-operatively

 

Intra-operative undisplaced fracture + Stable cup

- 2-4 screws through cup

- TWB 2-3 months

 

Intraoperative displaced fracture

- remove cup

- plate posterior column if factured

- screw fixation anterior column

- additional screws in cup

- +/- antiprotrusio ring                    

- TWB 2-3 months

 

THR Fractured AcetabulumTHR Fractured Acetabulum 2THR Fractured Acetabulum 3

 

Diagnosis Post operatively

 

Can be difficult to diagnose & image

- if unexplained groin pain post-op & press-fit cup 

- look for fracture with multiple oblique views etc

- CT

- may see callous formation

 

THR Intraoperative Acetabular Fracture

 

Post-operative early

 

1. Non or minimally displaced

- recognised immediate post-op

- TWB 3 months

 

2. Displaced fracture unstable

- ORIF & revise cup

 

Post-operative late

 

Peterson & Lewallen JBJS Aug 1996

 

Type 1

- cup clinically & radiologically stable

- no treatment

 

Type 2

- cup unstable

- revise as above

 

THR Femoral Fracture

 

THR Femoral Intraoperative FractureUncement Femur Intraoperative Fracture

 

Incidence

 

Increased incidence with press-fit components

- act like splitting wedge

 

Fracture may occur during

 

1. Dislocation

2. Reaming or broaching

3. Impaction of component

4. R/O cement or old components 

 

Prevention

 

During dislocation

 

Beware in elderly, osteoporotic patient and in revision

- adequate exposure

- only 1 person manipulate femur

 

If difficult dislocation

- complete ST release

- removal of acetabular osteophytes

- ankylosed joint or protrusio, division of neck in situ & piecemeal removal of femoral head

 

During femoral preparation

 

Pre-op templating of component size

- use of reamers before broaching to remove endosteal bone

- gentle broaching with pause if failing to advance

- sufficient broaching for easy prosthesis insertion

 

Avoid creation of stress risers i.e. cracks, defects, windows

 

If cracks or defects created

- bypass with implant by 2-3 cortical diameters distally

- minimise cement extravasation as prevents healing of defect

- use cerclage wires to prevent propogation of fracture

 

During component insertion

- gentle impaction with pause if failing to advance

- uncemented components often 1 - 2 mm proud of equivalent sized broach

 

Management

 

Vertical split not beyond LT

- cerclage wire

 

Vertical split beyond LT 

- cerclage wires

- longer stem

 

Perforation of shaft

- bypass defect

- fixate with plate

 

 

 

 

Investigation of Pain

Aetiology

 

Intrinsic

 

Infection

 

Loosening

 

Thigh pain in uncemented

- micro motion at distal end of stem

- modulus mismatch

 

Stress fracture / insufficiency fracture

- pubic rami, sacral

 

Intra-operative fracture

 

Prosthesis failure

 

Subtle instability

 

Extrinsic

 

Muscular tendonitis

- irritation of Psoas

- stretching of Adductors

- vas lateralis herniation

 

Trochanteric bursitis / tear G medius

 

Non-union of Trochanteric Osteotomy

 

THR GT Nonunion

 

HO

 

Lumbar / Knee / Pelvic / Abdominal pathology

 

History

 

Nature of Pain

 

°Pain-free interval  

- indolent infection

- pathology elsewhere (pain same as pre-op)

- poor implant fixation

- impingement

 

Pain-free interval 

- loosening

- infection

- implant failure

 

Mechanical pain 

- loosening

 

Start up pain

- pain with initial movement

- recedes as implant settles

- loosening symptoms

 

Rest pain / night pain 

- infection

- tumour

 

Location

 

Buttock / groin pain 

- cetabular pathology

 

Thigh / knee pain 

- Femoral pathology

 

Pain over GT suggests

- trochanteric bursitis / tear G medius

- Non-union of trochanteric osteotomy

 

Pain in other locations 

- spinal stenosis 

- knee OA 

 

Radiating below knee

- radiculopathy

 

Infection

 

Drainage postoperative suggests +++ infection if > 1/12 post-op

History of bacteraemia suggests infection

Prolonged in hospital ABx treatment

 

Examination

 

Pain with ROM 

- loosening - extremes of motion

- infection - pain throughout motion

- implant failure

 

Tenderness over GT

 

Wound 

- induration, erythema & drainage

 

Spine, knee & vascular  exam

 

Groin for inguinal hernia

 

Xray

 

Problems

 

1. May be normal in face of pathology

- serial comparison very important

 

2. Difficult to differentiate infection v loosening on XR

 

Infection

 

Infected THR Endosteal ScallopingInfected THR Periosteal New Bone

 

1. Radiolucent lines

2. Focal Osteolysis with Endosteal scalloping

3. Periosteal new bone 

- almost pathognomonic

- usually at junction meta / diaphysis on medial side

- only seen in 1-2%

 

Loosening

 

Easier to identify loosening in femur than acetabulum

- femur 90% accuracy

- acetabulum 65% accuracy

 

Lucent lines don't necessarily represent problem

- may be present in well-fixed prosthesis (retrieval studies)

- due to remodelling

 

WCC

 

Little value

- increased in 15%

- raised only if sepsis +++

 

ESR 

 

> 30 mm = 80% sensitivy & specificity for infection

 

Problems

- takes 6 - 12 / 12 to normalise post OT

- very non specific, increased in RA and remote pathology

- can be raised in aseptic loosening

 

CRP 

 

> 10 mg/l = 90% sensitiviy & specificity

- rarely increased with loosening

 

More predicable response post OT

- peak 2/7 (~400)

- normal after 3 /52

 

In the absence of other causes of elevation

 

If CRP is negative can be confident is no infection

- negative predictive value 99%

 

If CRP is positive is still a 20% chance that is no infection

- positive predictive value 75%

 

IF both ESR > 30 and CRP >10, 84% probability of sepsis

 

Te99 Scan

 

Bone scan may show increased uptake from

- infection

- loosening

- HO

- Paget's

- stress fracture

- large uncemented stem (modulus mismatch)

- tumors

- RSD

 

Advantage

- pathology unlikely if negative

 

Disadvantage

- very sensitive

- poor specificty

- doesn't differentiate cause

 

Lieberman et al JBJS Br  1993

- no benefit of NMBS over x-ray in diagnosis of infection or loosening

 

Residual activity 

 

Cemented 

- majority return to normal by 1 year

- 20% remain hot at portions of stem / GT / LT past 1 year

 

Uncemented 

- can remain hot for 2 years 

- can remain hot at distal stem for many years

 

Infected prosthesis

 

All phases increased & usually diffuse in 3 phases

- highly suggestive of infection

- can get focal uptake similar to loosening but rarer

 

Loose prosthesis

- localised increased uptake on delayed phase only

- motion of prosthesis causes increased bone turnover due to bone resorption 

- increased uptake @ GT & LT alone may be normal post op change

- well advanced loosening can show diffuse uptake as for an infected hip

 

THR Bone Scan NormalTHR Hot Cup Quiscent Femur

 

Stress sites 

- will see localised area of uptake on scan

- corresponds with cortical thickening on plain XRs

 

Insufficiency fracture

- occur in osteopaenic patients

- pubic rami fractures may cause groin pain

- sacral fractures may cause posterior hip pain

 

Indium 111 Labelled WC Scan 

 

Uncertain role 

- expensive, difficult 

- have to harvest WC

 

More specific for infection

- especially when combine with bone scan

- sensitivity 92%

- range specificity 75 - 100%

 

Aspiration

 

THR Aspiration

 

Technique

- no Abx >4 weeks

- II control & with contrast / confirm in joint

- no LA (bacteriostatic)

- aspirate hip joint x 3 specimens

- if only 1 specimen positive then repeat

 

If dry, inject normal saline & aspirate 

- controversial

 

> 65% PMN infection likely

> 1600 white cells microlitre

 

Results

 

Harris & Barrack JBJS 1996

- 2% positive rate if aspirate all hips

- therefore be selective

 

Lachiewicz et al JBJS Am 1996

- hip pain and elevate ESR

- 92% sensitivity & 97% specificity

 

HCLA

 

Crawford et al JBJS 1998

- 95-100% sensitivity

- ff good results from LA expect same from THR

- demonstrates that the pain is from the hip

 

Intra-Operative Frozen Section

 

PMN Cell Count 

- 40x power, count white cells in that field

- average over 10 fields

 

Mirra 1976 > 5phpf

- 84% sens, 96% spec

 

Lonner 1996 > 10phpf

- 84% sens, 99% spec

 

Intra Operative gram stain & m/c/s

 

Gold Standard

- 10% false positive

- Gram stain sensitivity < 20%, but very specific

 

All revisions no antibiotics for 4 weeks prior

 

Surgical Opinion

 

Sensitivity 70%

Specificity 85%

 

Management

 

Algorithm

 

Xray N / Scan N / ESR & CRP N

- not infected

- explore extrinsic causes

 

Xray Loose / ESR & CRP raised 

- infected

- 2 stage revision with intra-operative M/C/S

 

Xray normal / Hot scan / Raised ESR & CRP 

- infected

- 2 stage revision

- intra operative FFS to confirm

 

Xray / Scan / ESR / CRP all equivocal 

 

Aspirate

 

 

Leg Length Discrepancy

Issue

 

Most common reason for litigation against orthopaedic surgeons in THR

Usually from lengthening

 

Complications of LLD

 

1.  Nerve palsy

 

Sciatic nerve - tolerate average 4.4cm lengthening

 

Common peroneal nerve - tolerate average 2.7 cm lengthening

 

Lengthen by up to 15-20% of the resting nerve length

- but in reality is unknown and multifactorial

 

2.  Lower back pain / scoliosis

 

THR LLDTHR LLD with secondary scoliosis

 

3.  Abnormal gait

 

2 - 4 cm discrepancy

- significant increase in oxygen consumption

- also risk of falls

 

Assessment of LLD

 

Preoperative

 

Examination

 

Functional LLD

- blocks

 

Apparent LLD

- umbilicus to medial malleolus

 

True LLD

- ASIS to medial malleolus

 

Apparent shortening

- FFD & adduction hip

 

Apparent lengthening

- abduction contracture 

- scoliosis, fixed pelvic tilt

 

Consent

 

Very important

- must mention LLD

 

X-ray Assessment

 

AP pelvis 

- both femurs IR 15o

- compensate for anteversion

 

Templating

 

THR Template LLDTHR Leg Length Ischial LineCentre of Rotation Ranawat Method

 

1.  Establish Centre of rotation

 

Acetabular Templating

A.  Ilioischial line / Inter-tear drop line / Superior edge acetabulum

B.  Ranawat

- intersection of ilioishial and shenton's

- 5 mm laterally

- 1/5 pelvis up and 1/5 pelvis in

C.  Rule of thumb

- 2 cm horizontal and 4 cm vertical from teardrop

 

2.  Calculate LLD

- draw line LT / ischial tuberosity / inferior teardrop

- up to centre of femoral head / centre of rotation

- beware adducted hip on x-ray / false shortening

 

LLD with hip adduction

 

3.  Femoral Templating

 

A.  Size implant

B.  Determine offset

C.  Determine femoral osteotomy from lesser trochanter to restore LLD

 

Intra-operative

 

1.  Leg to leg comparison

 

Careful patient positioning

- ASIS perpendicular to floor and patient stable

- ability to palpate both knees and feet

- small pillow to prevent adduction of superior leg

- feel LLD before surgery in this position

- upper femur often feels 1 cm short even if no LLD due to adduction

- aim to reduce LLD to normal after reduction of THR at end of case

 

2.  Intra-operative measurement

 

System

- proximal pin in superoacetabular region

- distally diathermy mark in vas lateralis

- calliper measures horizontal distance (LLD) and vertical distance (offset)

- must place leg in similar position each time to measure leg distance

 

3.  Tests

 

Shuck test

- distract femoral head from acetabulum

- should be only few mm of shuck with correct tension

 

Drop Kick Test

- with thigh extended, knee should remain flexed

- if tension too tight, knee will extend

 

ROM

- if hip tension too tight, ROM especially IR / ER / extension is limited

 

Postoperative

 

Transient Perception of LLD

- 14% patients

- usually passes

- may have had LLD before which has been adjusted

- will then feel that leg is longer / which is true

 

Overlengthening

- may get back pain

 

Shortening

- abductor weakness

- even dislocation

 

Management

 

Delay using shoe lift for 6/12

- allows perceived LLD to resolve

 

Rarely revision surgery is required

- persistent neurological pain

- beware instability

 

 

 

 

Nerve Injury

Epidemiology

 

Primary THR 1%

Revision THR 3%

DDH  5%

 

Sciatic nerve 90% of nerve palsy

 

Other

- femoral nerve

- CPN

- ulna / radial nerve from positioning

 

Aetiology

 

Direct 

 

Laceration

- exposure / sciatic and superior gluteal nerve

- drill reamer / obturator nerve

- spike of cement / obturator nerve

 

Thermal

- diathermy

- cement / obturator nerve

 

Indirect

 

Compression

- cerclage wires

- anterior acetabular retractors / femoral nerve

- posterior femoral retractors / sciatic nerve

 

Haematoma

- post op sciatic nerve palsy

 

Strap / Pillow (COPN)

 

Traction

- LLD > 4cm

- dislocation

 

Prognosis Nerve injury

 

Femoral > COPN  > Sciatic

- most have some residual loss

- 80% incomplete recovery over 18 month period

- none after this

 

Good prognostic signs

- retention of motor function

- recovery of motor function initial few days

 

Document neurological status prior to indexed procedure

 

Poor prognostic signs

- nil recovery by 7 months

- causalgia

- elderly

- poor medical condition

- DM, alcoholism

- spinal stenosis (double crush)

- smoking, steroids

 

Superior Gluteal Nerve

 

Anatomy

- L4/5 S1

- sciatic notch above piriformis

- runs between G. medius and minimus

- supplies G. medius and minimus & TFL

 

Injury

- anterior / SP approach injure branches to TFL

- lateral / Hardinge approach respect safe zone in G. medius 3-5 cm proximal to GT

 

Obturator Nerve

 

Anatomy

- L2-4 posterior division

- along sacral alar

- emerge obturator foramen

- sensation to medial thigh

- adductor muscles

 

Injury

- screws / cement / reamers / retractors

- antero-inferior quadrant of acetabulum

 

Sciatic Nerve

 

Epidemiology

- most frequently injured nerve

- 1.5%

 

Anatomy

 

L4/5 S1-3

- emerges at G. sciatic notch

- usually tibial and peroneal components combined

- below piriformis

- below gluteals and above short ER

 

Variations

- can be in tibial and CPN divisions

- one or both divisions can run through piriformis

- both emerge above pirifomis

- always treat pirifomis with care in posterior approach

 

Runs over long head of biceps femoris under gluteal insertion

- passes between LHB and adductor magnus

- SHB only thigh muscles supplied by CPN component

 

Motor

- CPN: DF and evertors

- Tibial: PF and invertors

 

Sensory

- Sural: medial sural from tibial / lateral sural from CPN

- Superficial and Deep Peroneal nerve

- Tibial nerve

 

Aetiology

 

Traction 

- > 4cm lengthening in DDH 30% nerve palsy

- 0% if less than 4 cm

 

Compression

- posterior retractors / posterior acetabular wall

- post operative haematoma (CT scan)

- wires or cables (around femur)

- sutures (in closure at end of case)

 

Direct laceration

- revision surgery

- posterior approach

- DDH, Protrusio (nerve in abnormal position)

 

Ischaemia

 

CPN division

 

More vulnerable than Tibial branch

- fixed at fibular head

- more superficial than sciatic nerve

- less surrounding connective tissue

 

Examination

 

Sciatic nerve / CPN only / Tibial nerve only (very rare)

 

NCS

 

Determine if CPN at level of hip or knee

- function of short head of biceps

 

Management

 

Explore if cause is haematoma

- delayed onset or late progression of palsy in setting of haematoma 

- CT may be useful to diagnose

 

Explore if believe major direct injury

- transection or entrapment in cerclage wires

- sutured

 

Otherwise few indications to explore

 

Femoral Nerve

 

Anatomy

 

L2-4

- enters femoral triangle between psoas and iliacus

- power to quadriceps

- sensation to medial thigh and calf

 

Aetiology

 

Compression

- anterior retractors above psoas in anterior approaches to the hip

- iliacus hematoma / bleeding tendencies

 

Femoral nerve blocks

 

Injury

- cement extrusion / screws AS quadrant

 

Clinically

 

Anteromedial numbness

Difficulty climbing stairs

 

Prognosis

 

Very rare 0.4%

- usually recovers in full

 

 

 

 

 

Periprosthetic Fracture

TypesTHR Periprosthetic Fracture

 

Peri-operative

- incurred during operation

 

Post operative

- related to osteolysis / trauma / infection

 

Follow up

 

1994 National Institutes of Health Consensus on THR

 

Regular radiographic follow-up to avoid massive osteolysis & fracture

 

Incidence

 

Primary

 

0.6% cemented

0.4% uncemented

 

Revision

 

2.5% cemented revision

1.5% uncemented revision

 

Aetiology

 

1. Bone damage at insertion

- eccentric reaming

- perforation

- fracture

 

2. Osteolysis

 

3. Trauma

 

4. Infection

 

5. Osteoporosis

 

Vancouver Classification

 

Type A (4%)

 

Avulsion GT or LT

 

A1 Stem well fixed

A2 Stem loose

 

Type B (87%)

 

Fracture near stem tip or around stem

 

B1 Stem well fixed (20%)

B2 Stem loose (44%)

B3 Stem loose with marked osteolysis (36%)

 

Type C (10%)

 

Fracture distal to tip

 

Management

 

Most important is whether prosthesis is stable

- if loose requires revision

 

Type A

 

Avulsion GT or LT

 

Management

 

GT

- undisplaced - no treatment required

- ORIF GT if displaced > 2.5 cm / disruption to abductors

 

THR Periprosthetic Type A THR Periprosthetic Fracture A PlatingVancouver A Displaced GTVancouver A GT Wire Fixation

 

LT

- cerclage LT if large and supportive

 

Type B1 

 

Fracture around stem, likely well fixed

 

THR Periprosthetic Fracture B1THR Periprosthetic Fracture B1 Lateral

 

Options

 

1.  ORIF with cable plate + proximal unicortical locking screws +/- Cortical strut graft

 

Cable plate alone

- 90% union

 

Locking Cable plate + single strut graft

- 98% union

- distal bicortical screws

- proximal unicortical screws supplemented with cables

 

Cortical Strut Graft

 

2.  Long stem revision

 

Cemented

 

THR Periprosthetic Revision Long Cemented FemurTHR Periprosthetic Revision Cemented Femur 2

 

Uncemented

 

THR Periprosthetic Fracture Type B1THR Fracture Long Stem Revision

 

Type B2

 

Fracture around stem, femoral component loose

 

THR Periprosthetic Fracture B2Periprosthetic Fracture Vancouver B2

 

Options

 

Long stem revision

- distal fit (cemented / uncemented)

- must bypass distal extent of fracture by at least 2 cortical diameters

 

THR Periprosthetic Fracture B1 Long stem cemented revision

 

May in addition use

- cable plate + unicortical locking screws

- 1 x strut allograft

- autogenous BG + BMP to fracture site

 

Revision THR Periprosthetic Fracture Uncemented Stem Strut GraftRevision THR Periprosthetic Fracture Uncemented Stem Strut Graft 2Revision THR Periprosthetic Fracture Uncemented Stem Strut Graft 3Revision THR Periprosthetic Fracture Uncemented Stem Strut Graft 4

 

Vancouver B2 PFFRevision PFF with Modular Uncemented and Strut Allograft

 

Type B3

 

Fracture around stem with marked osteolysis

 

THR Vancouver B3 APTHR Vancouver B3 Lateral

 

Options

 

Young patient

- segmental allograft / prosthesis composite

 

Elderly

- tumour type proximal femoral replacement

 

Type C 

 

Fracture distal to tip of stem

 

Options

 

1.  ORIF Cable Plate

- can use MIPO

- overlap femoral stem to avoid stress riser

 

THR Periprosthetic Type C Plating

 

2.  ORIF Cable Plate + cortical strut graft

 

2.  Strut allograft alone

- use 2 x 1/2 femurs fresh frozen

- span fracture 10cm above & below

- 4 wires above & below

- preserve blood supply to linea aspera

- autogenous graft to fracture site

 

THR Consent

 

THR Complications

 

Early

 

Infection (1% risk deep infection)

Wound Haematoma

Bleeding / Transfusion

Dislocation (2 - 3% recurrent)

NVI

Fracture

DVT/PE (Fatal PE 1/1000 with chemoprophylaxis)

LLD (average 1cm, stability more important)

Medical complications

- pneumonia, UTI, CVA. IHD

Death

 

Late

 

Limp (LLD, 1 year with anterolateral approach)

Loosening / Revision (95% 10 year survival)

HO (1% Problematic)

Thigh pain (uncemented stems)

Continued pain

Thigh Pain Uncemented Femur

Epidemiology

 

Ranges

- up to 4%

 

Clinical

 

Focal pain

- typically anterolateral thigh

- often tender

- corresponds to tip of stem

 

Aetiology

 

1.  Instability

 

Types

- early

- late / failed bony ingrowth

 

Cause

- micromotion at distal stem

- disadvantage of proximal coating

 

2.  Mismatch modulus of elasticity

 

A.  Component material

- mismatch between femoral component and surrounding bone

- lower with titanium stems compared with cobalt chrome stems

- titanium components less stiff & tend to have lower incidence of thigh pain

 

B.  Stem size

- more commonly seen in larger stems

- increases relative stiffness of stem compared to bone

 

3.  Stem design

- distal flutes can decrease distal stiffness

- fully porous coating decreases incidence, but increases proximal stress shielding

 

4.  Osteoporotic bone

- more commonly seen with lower bone quality

 

DDx

 

Loosening

- start up pain

 

Infection

 

Xray

 

Loosening

- migration

- progressive radiolucent lines

- abscence of spot welds

 

Bone Scan

 

No correlation of findings with thigh pain

 

Management

 

Non operative

 

Up to 2 years

- allows for remodelling

 

NSAIDS

Physio

 

Operative

 

1.  Cerclage wire cortical strut grafts

 

Theory

- improve bony rigidity over distal stem

 

Technique

- application to lateral femur

- overlap tip proximally and distally 8 cm

- must get host bone integration

- periosteal elevation / bone graft / rigid fixation

- TWB 6 weeks post op

 

Results

- good results reported

 

2.  Revision

 

 

 

 

 

Vascular Injury

Vessels at risk

 

Extra-pelvic blood vessels

 

Femoral Artery

MCFA

LCFA

Profunda Femoris

Obturator artery

 

Intrapelvic vessels

 

External iliac artery and vein

Obturator artery

Superior and inferior gluteal

 

External Iliac Vessels

 

Anatomy

- anterior division of common iliacs / L5-S1

- runs down medial border of Psoas

- some psoas between EIA & intrapelvic surface of anterior column

- EIV accompanies EIA

 

Injury

 

Screws 

Cement

 

Screws

 

Screws may penetrate VAN

- can be delayed diagnosis

- significant intrapelvic bleeding may occur before diagnosis

- AS quadrant: minimal protective ST interposition and often poor bone stock

- vein more at risk than artery

 

CementIntrapelvic cement THR

 

Aetiology

- heat

- kinking or occlusion from bolus

- erosion from spicule

- avulsion secondary to removal

 

Avoid cement intrusion into pelvis with wire mesh 

 

Removal of intrapelvic cement

- required in revision for infection

- define NV relationships

- angiography / MRA preoperatively

- may require separate intrapelvic exposure

- alert general surgeons / vascular surgeons

 

Femoral blood vessels

 

Most commonly injured

 

Anatomy

- common femoral artery is continuation of EIA as passes under inguinal ligament

- passes anterior to hip capsule

- separated from it by psoas

 

Injury

 

Anterior retractors / dissection

Anterior quadrant screws and drills

 

Obturator AV

 

Anatomy

 

VAN traverse lateral wall together

- separated from quadrilateral plate by obturator internus

- lie at superolat aspect of obturator foramen

- exit pelvis via obturator canal

 

Injury

 

Screws in AI quad

Retractor under transverse acetabular ligament

 

Management

 

Bleeding at inferior transverse ligament

- can be very difficult to ligate

- pack with swab

- hold swab with inferior retractor

- finish acetabulum

- will usually be controlled

 

Other option is to embolise if still bleeding

 

Superor Gluteal BV

 

Anatomy

 

Branch Posterior Division IIA

- close to posterior column

- exits greater sciatic notch above piriformis

 

Injury

 

Screw near sciatic notch

 

Inferior Gluteal & Internal Pudendal AV

 

Anatomy

 

Branch anterior division IIA

- exit pelvis between piriformis & coccygeus

- close to posterior column near ischial spine

- internal pudendal artery re-enters pelvis through lesser notch

- IGA pass under piriformis

 

Injury

 

Very long screws through posterior column

 

Management on table torrential bleeding

 

Pack wound, tell anaesthetist & vascular surgeon & obtain proximal & distal control

 

Notify anaethetist

 

IV fluids

Coags,  FBC, platelets,  cross match

Transfuse blood

Organise cell saver

 

Control bleeding

 

Pack & wait

- uncontrollable, get proximal control

 

Call Vascular surgeon

 

Ilioinguinal approach

- clamp IIA, vessiloop IIV

 

Retro-peritoneal approach

- Rutherford-Morrison incision

- retroperitoneal approach

 

Post-operatively

- angiography

- transcatheter embolisation

 

 

THR Difficult

Arthrodesis Conversion

Indications

 

Severe LBP 

- most common indication

 

Ipsilateral knee pain

- less beneficial

 

Malposition

- especially abduction

 

Contraindications

 

Absent abductor mechanism

Flail

Active infection

Insufficient bone stock

 

Examination

 

LLD

 

Assessment abductor function

 

1.  Palpation whilst asking patient to contract

2.  MRI

 

Issues

 

1.  Difficulty prepping & draping

 

2.  Exposure

- identify sciatic nerve

- perform GT osteotomy

- may require adductor & psoas tenotomy

 

3.  LLD

- maximum 4cm lengthening 

- use ASIS pin as LLD guide

 

Xrays

 

Hip Fusion 1Hip Fusion THR 1

 

Hip Fusion 2Hip Fusion THR 2

 

Hip Fusion 4Hip Fusion THR 4

 

Hip Fusion 5HIp Fusion THR 5

 

Results

 

Joshi et al JBJS Am 2002

- 208 hips converted at average 51 years

- average follow up 9 years

- 83% good to excellent function

- 96% 10 year survival

- 15 nerve palsies

 

Complications

 

Loosening

Infection

Sciatic nerve palsy

HO

Residual LLD

Poor abductor function

 

 

DDH

ConceptTHR Dysplasia Subtrochanteric Osteotomy + Mesh Impaction Bone Graft

 

THR in dysplastic hips has a higher failure rate

- due to anatomic abnormalities

- due to generally younger age

 

Aim

 

Restore normal biomechanics and preserve bone stock

 

Issues

 

Soft tissues

 

Sciatic nerve in abnormal position / danger

Hamstring  / adductors / RF tight

Horizontal abductors - function less efficiently

Thick hourglass capsule

Thickened psoas tendon

 

Acetabulum

 

Low subluxation

- shallow with wide opening

- small

- deficient anterior / lateral / superior

- better bone stock posteriorly

 

DDH Anterior Acetabular Insufficiency

 

High dislocation

- small pelvis

- thin & soft acetabular wall

- gross anteversion

 

Femur 

 

Increased anteversion

- valgus neck shaft angle

 

Narrow tapered femoral canal

- tight isthmus

- AP diameter > ML

 

Posterior displacement of the greater tuberosity

 

LLD

 

Can be very short

- maximum sciatic nerve can be lengthened is 4 cm

 

Crowe Classification

 

Based on extent of proximal migration of femoral head compared to the height of the undeformed femoral head

- femoral head is 20% height of pelvis

- measure the vertical distance between the inter-teardrop distance and the head neck junction

- this distance as a ratio of the femoral head

 

Crowe I:  Proximal displacement < 50% femoral head (10% pelvis)

 

DDH Crowe 1

 

Crowe II:  Proximal displacement femoral head 50-75%                            

 

DDH Crowe 2Crowe 2 DDHCrowe 2 DDH Lateral

 

Crowe III: Proximal displacement femoral head 75 - 100%

 

DDH Crowe 3DDH Crowe 3DDH Crowe 3 Lateral

 

Crowe IV:  Proximal displacement femoral head >100% (20% pelvis)

 

Efekhar Classification

 

A Elongated dysplastic acetabulum

B Intermediate acetabulum

C High false acetabulum

D High but no false acetabulum

 

Examination

 

Pelvic tilt

Lumbosacral flexibility

Fixed hip deformities

Real and apparent LLD

Previous scars

 

Operative Management

 

Aim

 

Restore hip centre

Acetabular bony coverage

Restore LLD

 

Technical Factors

 

Soft tissue release

- capsule / psoas / adductors / abductors

- abductor slide or release from ilium

- protect sciatic nerve

 

Acetabulum

- need small components

- restore centre of rotation / bring down to true floor

- may need to augment superolateral acetabulum

 

Femur

- small components

- correct femoral anteversion

- restore offset as best able

- may require trochanteric slide

 

LLD

- > 4 cm need femoral osteotomy

 

Acetabular component

 

Options

 

1.  Restore normal hip centre

2.  High hip centre

3.  Medialise cup 

 

Restore normal hip centre

 

A.  Recreate centre of rotation

 

Place in true acetabulum

- transverse ligament is anatomical landmark

 

Template hip centre

- inter-tear drop line is inferior margin

- ilio-ischial line is medial margin

- superior edge acetabulum lateral margin

 

B.  Need for augmentation

 

Superior defect must be < 30%

 

Options

- bulk femoral head autograft

- mesh + impaction bone graft

- reinforcement rings / cages

- augmented cups

 

Acetabulum Reconstruction

 

Bulk Femoral Head Autograft 

 

DDH Bulk Femoral Head Autograft

 

Advantage

- restore hip centre

- improve bone stock for revisions

 

Technique

- fashion femoral head into 7 graft

- screw into place with 2 x 6.5 mm cancellous screws

- ream into inferior aspect of graft

 

Spangehl et al JBJS Am 2001

- 44 hips followed up for 7.5 years

- femoral autograft with uncemented cup

- 4 revisions / 10%

- acceptable early results

 

Harris JBJS 1997

- 55 autogenous bulk autograft + cemented acetabulum

- average follow up 16.5 years

- average age of patient at time of surgery 42 years

- average size of acetabulum 40mm

- average coverage of cup by graft 49%

- 29% (16/55) revised and further 31% (17/55) radiographically loose

- those grafts 30% or less of cup coverage were well fixed at 16 years

- the greater the coverage of bone graft initially, the greater the rate of late revision

- most hips did well for initial 5 - 10 years

 

Mesh + Impaction Bone Grafting

 

DDH THR Rim Mesh Allograft

 

Reinforcement ring / cage + bone graft

 

Technique

- morcellised bone graft

- support with acetabular reinforcement ring

- usually screwed into ilium and ischium

- cement acetabular component into ring

 

Muller JBJS 1998

- 87 hips, majority Crowe 3

- Muller acetabular roof reinforcement ring

- autograft and cemented polyethylene cup

- 10% revision at 9.4 years

 

Ganz J Arthroplasty 2005

- 33 cases at 10.8 years

- 3 revisions (9%)

- 2 of the revisions had structural allograft

 

DDH augmented cups

 

High Hip Centre

 

DDH THR High Hip Centre

 

Advantage

- allows coverage by native bone

- decreases need for femoral shortening

 

Disadvantages

- very small acetabular component

- very thin poly

- abnormal hip biomechanics

- risk of bony impingement 

- may lateralise hip centre

 

Results

 

Kaneuji et al J Arthroplasty 2009

- 30 hips followed up for 15 years

- mild superior hip centre compared to contralateral normal hip (13 mm average)

- 1/30 revised

 

Socket medialisation / acetabuloplasty / medial protrusio technique

 

Technique

- controlled medialisation with deliberated over-reaming

- can deliberately fracture medial wall

 

Advantage

- improves lateral coverage

- decreases JRF through medialisation

 

Disadvantage

- loss of medial bone stock compromising future revision

- risk of early catastrophic component migration medially into pelvis

 

Results

 

Femur

 

Issues

 

Small and narrow

Excess anteversion

 

Management

 

Small components

 

Uncemented

 

Need to be modular

 

A.  Abnormal shape of proximal femur

- difficult to obtain press fit / risk fracture

- diaphyseal press fit

- small modular metaphyseal component

 

B.  Need modularity to adjust anteversion

- SROM prosthesis

- dial in version

 

Cemented DDH prothesis

 

Design

- smaller with minimal metaphyseal flare

- this allows stem to be orientated independently of patients anteversion

 

LLD / Abductor Tension

 

Issues

 

Only lengthen sciatic nerve 4cm

Abductors very tight and prevent lengthening

Difficulty reducing hip

 

Difficulty reducing hip

 

1.  Psoas release

2.  Subtrochanteric osteotomy

3.  GT osteotomy

 

Tight abductors

 

Trochanteric slide allows

- acetabular exposure

- retensioning abductors

- reposition abductor insertion to correct anteversion

 

LLD

 

Subtrochanteric osteotomy

 

THR DDH Subtrochanteric Osteotomy

 

Advantage

- acetabular exposure (lift up)

- correction anteversion

- shortening femur 

 

Technique

- mark rotation with 2 x small drill holes

- make osteotomy

- transverse osteotomy allows rotational adjustment

- step cut more difficult but gives rotational stability

- insert trial femur proximally

- reduce hip joint

- calculate resection based on overlap of proximal and distal femoral segments

- uncemented or cemented stem

- use bone resected as onlay

 

Management Algorithm

 

Acetabulum

 

Crowe I

 

Mildly dysplastic

- minimal deformity, good bone stock

- small standard cup medialised for coverage

- < 30% uncovering allowed

- small femoral stem

 

Crowe II / III

 

Usually very deficient laterally

- due to femoral head eroding acetabulum

- restore hip centre by reaming medially

- then need to provide superolateral coverage

- autograft + mesh / allograft / DDH cup / tantalum

 

Crowe IV

 

Usually good bone stock in true acetabulum

- femoral head has not eroded bone

- recreate acetabulum and place small component

- use teardrop and fovea as landmarks

 

Femur

 

Crowe I/II

 

Minimal LLD

- sess femoral shortening required

- avoid excessive anteversion based on abnormal femoral neck

- otherwise get anterior instability and loss ER

 

Crowe III/IV

 

If greater than 4cm LLD

- need to shorten femur

Neuromuscular

Categories

 

Decreased tone

- Polio

- Down's syndrome

- spina bifida

 

Increased tone

- cerbral palsy

- Parkinson's

- CVA

 

Polio

 

Rare

- case reports only

 

Down's Syndrome

 

Acetabular dysplasia not uncommon in this group

 

Results

 

Kloschos et al JBJS Br 2002

- 6 patients

- 7 year follow up

- all doing well

 

Cerebral Palsy

 

Options 

- THR

- resection arthroplasty

- pelvic support osteotomy

- arthrodesis

 

THR offers best pain relief and function

 

Problems

 

Young patient

- abnormal muscle strength

- spasticity and contractures

- co-operation issues

- functional demand is low

 

Results

 

Schroeder et al Int Orthop 2010

- 18 THR in ambulatory patients

- 10 year follow up

- 1 recurrent dislocation

- 3 aseptic loosenings

 

Parkinson's disease

 

Issues

- poor neurological status

- progressive worsening with dementia

- high risk dislocation

 

Results

 

Weber Int Orthop 2002

- no dislocations in 58 primary THR for Parkinson's

 

Osteogenesis Imperfecta

 

OI THR

 

 

 

Perthes

Issues

 

Femur

 

Multiplanar deformity

- worsend by previous surgery

- may require osteotomy

 

Acetabulum

 

Dysplasia often present

- not as severe as in DDH

 

LLD

 

Can be significant

 

Abductors

 

Have been short for long time

- difficult to restore length

- may require trochanteric slide

 

Perthes OA previous osteotomyPerthes THR

 

 

Bilateral Severe Perthes Hip OABilateral Perthes THR

 

Protusio

Definition

 

Migration of the femoral head past the medial wall of the acetabulum / ilioischial line 

 

Centre edge angle > 40o

 

Aetiology

 

Primary 

 

Otto's Disease

- bilateral in one third

- middle aged females

- pain & decreased ROM early 

- coxa vara & OA common

- ? causally related to osteomalacia

 

Bilateral Hip Protrusio

 

Secondary

 

PROFSHAMN

- Paget's

- RA

- osteomalacia / OI

- fracture / central dislocation

- septic arthritis especially TB

- hemiarthroplasty

- Ankylosing Spondylitis 

- Marfan's syndrome, malignancy

- Neurofibromatosis

 

Charnley classification 1978

 

Defined medial wall of acetabulum as ilioischial line

 

Grade I  1-5mm                                Grade II  6-15 mm                            Grade III   >15 mm

 

Hip Protrusio Grade 1                                                               Hip Protrusio Grade 3

 

Eldstein & Murphy 1983

 

Medial wall is acetabular line & ilio-ischial line

- men acetabular line 2mm lateral to ilioischial line

- women 1mm medial to ilio-ischial line is normal

 

Grade Men Women  
I 3 - 8 mm 6 - 11 mm  
II 8 - 13 mm 12 - 17 mm  
III > 13 mm > 17 mm with fragmentation  

NHx 

 

Inexorable progression of deformity

- axis of migration is same direction as joint reaction force in stance phase 

 

Management

 

Medical Workup

 

Identify and treat any underlying cause

- FBC, ESR, RF, ANA, ELFT, Ca

 

Options

 

A.  Skeletally immature 

 

Triradiate fusion

- can combine with valgising osteotomy

 

Steel et al JPO 1996 

- 22 patients with Marfan's syndrome

- 12 of 19 restored to normal

- 4 improved

- 3 unchanged

 

B.  Young adult 

 

Valgising intertrochanteric femoral osteotomy (VITO)

- patient < 40, minimal OA 

- may delay THR for 10 years

 

Aim for 20-30° valgus correction

- if neck shaft angle is 130° aim for 155°

- trapezoid shortening to minimise LLD

 

Lateralization of femur to restore mechanical alignment

 

Require soft tissue release especially psoas

 

C.  Middle aged / elderly

 

THR

 

THR Protrusio

 

Principle

 

Place hip center anatomically 

 

Restore joint biomechanics

- outcome depends on cup position

- adequacy of correction of the deformity & biomechanics correlates with long-term prosthetic survival

- medial joint positioning leads to high medial stresses

 

Results

 

Ranawat JBJS Am 1980 

- 35 hips with protrusio secondary to RA

- 16 of 17 THR >10 mm from hip centre loosened

- 13 THR with <5 mm out good survival

 

Determine Hip Centre 

 

1.  Teardrop

- average 2 cm vertical & 4 cm horizontal from teardrop

- average coordinates reported in normal adults 14 mm vertical & 37 mm horizontal

 

Hip Protrusio Teardrop Method Centre Rotation

 

2.  Ranawat Method 

 

Hip Protrusio Ranawat Method Centre Rotation

 

Draw parallel horizontal lines at the levels of the iliac crests and ischial tuberosity and mark 3 points

- Point 1: 5mm lateral to intersection of Shenton's and Kohler's lines

- Point 2: located superior to point 1 by a distance 1/5 of the pelvic height

- Point 3: similar distance horizontally from vertical line

 

Isosceles triangle between 1/2/3 locates the acetabulum 

- line 2/3 through subchondral bone

 

Management Bone Defects

 

1.  Assess medial wall integrity with CT

 

Hip Protrusio CT Medial Wall IntactHip Protrusio CT Medial Wall Intact 2

 

2.  Algorithm / Ranawat J Arthroplasty 1986

 

A.  < 5mm - no graft required

 

Hip Protrusio Grade 1THR Protrusio Type 1

 

B.  > 5mm but medial wall intact - morcellised bone graft

 

Hip Protrusio Type 3THR Protrusio Medial Morcellised Bone Graft

 

C.  No medial wall - mesh / cage + morcellised bone graft

 

Technique

 

Preoperative

- template LLD (max 4cm)

- define acetabular defect with CT

- ensure intact medially

 

Approach

 

1.  Sciatic nerve is nearer the joint than normal

- identify and protect early

 

2.  Dislocation of the hip can be difficult

- femoral osteotomy in situ + femoral head removal piecemeal may be required

- trochanteric osteotomy may be required for exposure

 

Reaming

- enlarge rim only

- avoid creating peripheral defect

 

Contained acetabular defect

 

Morcellised bone graft

- rim fit uncemented cup

- cemented cup

 

Uncontained acetabular defect

 

A.  Wire mesh / bone gaft / cemented cup

B.  Wafer bone graft / morcellised bone graft / cage / cemented cup

 

 

THR Primary

Background & Technique

IssuesTHR Uncemented

 

Templating

Approach

Fixation

Bearing Surface

Head Size

Offset

 

Indications

 

Disabling hip pain

Severe functional impairment

Failed non operative management

 

Not Indicated 

 

Painless deformity

Stiffness

LLD

 

Aetiology

 

1° OA

 

2° (accounts for maybe 50% OA hip)

 

Secondary OA

 

SUFE                                                          

 

Hip OA Post SUFEBilateral SUFEHip OA Post Sufe 2

 

DDH

 

DDH Crowe 1

 

Perthes

 

Hip OA PerthesHip OA Perthes 2Hip OA Perthes 3Hip OA Perthes previous osteotomy

 

Trauma                

 

Hip OA post Acetabular FractureHip OA post displaced Acetabular FractureHip OA Post NOF FractureHip OA post subcapital fracture

 

Paget's                                                                                                                             

 

Hip OA PagetsPagets Bone Scan  

 

AVN

                  

HIp OA Bilateral AVN

 

Coxa Vara                                                                                                                     

 

Hip OA Coxa VaraHip OA Coxa Vara 2                                              

 

Sepsis

 

Hip OA Post Sepsis

 

Tumour

RA

 

Contraindications

 

1.  Five Absolute

 

Active infection

Charcot

Flail / Neuromuscular impairment

Hypovascular

Inadequate soft tissue cover

 

2.  Five Relative

 

Young patient

Heavy demand

Obese

Poor compliance

Poor mental state

 

Pre-op Evaluation

 

General

- mobility

- life expectancy

- fitness for anaesthetic - ardiopulmonary

- urinary status / TURP before THR

- teeth

- NSAID / aspirin / plavix / warfarin

 

Hip

- abductor strength

- LLD

- contractures

- vascularity 

- check skin / scars

 

Medical workup

 

PMHx

- DM / RA / Hemophilia / Marfan's etc

 

Beware difficult hip

- DDH

 

Medical / Anaesthetic Review

 

CXR / ECG / FBC / UE / Coags / GP&H

 

Medications

- cease Aspirin / Warfarin

- steroids

- diabetic medications

 

Education & Advice

 

Informed consent

- infection

- NVI

- blood transfusion

- LLD

- dislocation

- fracture

- DVT / PE

- limp

- revision

 

Rehab starts pre-operatively

- home modifications

- discuss precautions (high chair, pillow at night)

- physio

- driving (usually not for 6 weeks)

- social worker / occupational therapy

- work arrangements

 

Equipment

 

X-ray

 

Requirements

 

1.  AP pelvis / AP of hip showing proximal femur / Lateral

 

2.  Lower extremities internally rotated 15° to 20° 

- to allow proper offset templating

- can roll patient if severe OA

 

3.  Magnification marker

- most XR departments use bulky tray placed in compartment

- 2 inches below table top

- resulting in magnification of 15% to 20%

- degree of magnification directly related to distance from bone to cassette

- obese magnification can be > 25%

- thin patient can be < 15%

 

Template 

 

Component Position

 

Leg length 

 

Neck-shaft angle 

 

Femoral offset 

 

Degree of acetabular dysplasia 

 

Acetabular bone defects

 

CT scan

 

Hip OA previous Acetabular fractureHip OA CT Anterior wall discontinuousHip OA Posterior Wall Intact

 

Consider

 

Fixation - cemented v uncemented

 

Bearing surfaces

 

THR Technique

 

Position

- on side on bed

- pressure area care / CPN / ulna nerve

- pelvis perpendicular to bed

- completely stable

- Charnley hip supports

- able to palpate both knees and feet for leg length

- small pillow between legs / comparable position

- saline bag under armpit

- TEDS / SCDs lower leg

 

Antibiotics

 

Antibiotics at induction

- broad spectrum: first generation cephalosporin

- allergy: vancomycin / clindomycin

- repeat if operation longer than half life / 2 hours

 

Approach

 

Options

- Posterior / Kocher-Langenbech

- Lateral / Hardinge

- Transtrochanteric / Charnley 

- Anterior / Smith Petersen

 

LLD

 

1.  Position of knees

- comparable position

- check LLD prior to incision

- aim to recreate equal LLD

- note:  adduction of superior leg will artificially shorten leg in this position

 

2.  Intra-operative

- pin in superior acetabulum

- mark on femur

- recheck with femur always in same position

- can measure LLD and offset

 

Acetabulum

 

Exposure

- anterior acetabular retractor / beware femoral nerve

- inferior acetabular retractor / beware obturator artery

- avoid posterior retractors / beware sciatic nerve

 

Preparation

- remove labrum and capsule

- may need to remove curtain osteophytes

- define true floor with gouge at transverse notch 

 

Reamer

- medialise initially to true floor

- medialisation decreases JRF

- to bleeding bone

- preserve anterior and posterior walls

 

Cemented cup

- ream 2 mm > cup size for cement mantle

- leave transverse ligament intact

- low viscosity cement / Palacos

 

Uncemented cup

- young ream 1 mm < cup size

- old ream 2 mm < cup size

 

Acetabular Orientation

 

Closure

- 40+/-10°

- 45o to bed

 

Anteversion

- 15 - 30°

- increase in posterior approach

- use pelvis as perpendicular to floor

- use inferior transverse ligament

 

Femoral Stem

 

Entry point

- bow chisel

- start lateral and posterior

- follow bow of femur

- pass reamers

- find centre of femur

- check not perforating femur 

 

Incremental increase in broaches

 

Uncemented

- until broach rotationally stable

- don't wash away good cancellous bone

 

Cemented

- leave some cancellous bone

- allows cement interdigitation

 

Orientation

- anatomical anteversion 15°

- neutral or slight valgus

 

Trial

- offset / neck length / head size / LLD / stability

 

Insert definitive component and retrial

- ensure stability / LLD

- apply definitive head

 

Closure

- irrigate to remove particles

- +/- drain

- pressure dressings

 

Post-operative Management

 

4 x doses broad spectrum antibiotics

Check Hb and electrolytes next day

Analgesia

Abduction Pillow - 6/52 nightime

TEDS / Compression - 6/52

Anticoagulation - 6/52

 

Early mobilisation with Physio

 

Precautions until pseuodocapsule forms

- no flexion >90°  6/52

- limit IR / adduction

- sit in high chair 6/52

- no driving / 6/52

Bearing Surfaces

Wear

 

The removal of material, with the generation of wear particles under an applied load and in relative motion

 

Tribology is the study of wear and lubrication

 

Wear mechanisms

 

Adhesion

- bonding of the surfaces when pressed together

- may pull away material from the weaker surface

 

Abrasion

- asperities on the harder surface cut and plough 

- remove materials from the softer surface

 

Fatigue

- repetitive local stresses exceed fatigue strength

 

Wear Modes

 

Mode 1

- from motion of two surfaces rubbing together

- as intended

 

Mode 2

- primary surface against a non intended secondary surface

- head eroded through poly and up against metal backing

 

Mode 3

- two primary surfaces with a third body

- roughens surface

- increases mode 1 wear

 

Mode 4

- two secondary surfaces / backside wear

- creates third bodies

- i.e. screw fretting or between liner and metal backing

 

Wear types

 

Linear Wear 

- radiographic change in thickness of socket at maximal point of wear  

- based on 2D Xray

 

Volumetric Wear 

- volume of particulate poly created

- calculated based on trigonometric formula

- in turn based on measured linear wear & square of radius of articulating head

- probably represents underestimation of actual volume of wear particles produced 

 

Now more sophisticated computer based systems more accurately estimate wear

 

Fluid-film lubrication

 

Completely separates surfaces

- when fluid film height is thicker than height of asperities on the surface

- decreases roughness

- decreases wear

 

Variables in amount of wear

 

Type of bearing surface 

Head size 

Acetabular orientation

Weight 

Sex 

 

Polyethylene

 

Repeating chain of ethylene monomers

 

Advantages

- low cost

- multiple options i.e. elevate rim

- high wear resistance

- no toxicity

 

Disadvantage

 

Wear particles very bioactive

 

Factors in Poly wear

 

1.  Preparation of poly effects longevity 

A.  Machined from extruded polyethylene bar stock 

B.  Compression moulded directly from the polyethylene resin

 

2.  Sterilisation & Aging

A.  Surface treatment

- ethylene oxide gas

B  Gamma irradiation

- in vacuum causes cross linking which decreases wear

- in air get oxidation which increases wear

 

3.  Highly cross linked

 

Occurs when free radicals from a covalent bond between PE molecules

 

Advantage

- improved wear resistance

- up to 95% wear reduction compared with normal poly

- ability to use larger head sizes

- normal liner must be 8 mm

- can decrease this thickness to allow larger heads

 

Disadvantage

- decreased yield and tensile strength

- like ceramic, is more brittle with increased wear resistance

 

4.  UHMWPE

- ultra high molecular weight polyethylene

 

5.  Poly thickness

 

Thicker poly diminishes stresses in subchondral bone & within poly

 

Metal heads / CoCr

 

THR Metal on Poly

 

Ceramic heads on poly

 

THR Ceramic on Poly

 

Types

- Alumina AL2O2

- Zirconia ZrO2

 

Harder

- more difficult to scratch

- reduce abrasive wear

 

Smoother

- can be polished to lower surface roughness

 

Wettability

- hydrophilic

- improved lubrication and lower friction

 

Wear

- 0.2 mm / yearr on 2D& 3D models

- may be reduced by 50% compared with metal on poly

 

Ceramic on ceramic

 

Advantages

 

Highest wear resistance

- invitro 0.007mm3 / million cycles

- CoCr / poly 70-90mm3 / million cycles

 

Wettability

- excellent lubrication

 

Smoothness

- can be highly polished

 

No toxicity

 

Disadvantages

 

Position sensitivity

 

Liner chipping

- must take care during insertion

 

Fracture risk

- was a worldwide recall of zirconia heads in 2001

- due to unexpectedly high fracture rate in zirconia heads from one manufacturer

- now about 1 / 10 000

 

No hooded liner available

 

May need to revise ceramic with ceramic

- particles remaining may be hard than new bearing surgace

 

Squeaking

 

Trunion damage in revision

- new ceramic head may not lock to new trunion

- can use ceramic head with metal neck augment inside it

 

Metal on Metal

 

THR Metal on Metal

 

History

 

Popular in the 1960's

- McKee-Farrar replacements

- abandoned

- partly because of poorer results than Charnley low friction arthroplasty

- partly metal sensitivity concerns

 

Interest was aroused when it was noticed in some patents very good survival rates at 20 years and beyond

- discrepancy between some patients doing very poorly and some patients doing very well

 

Second generation design

 

Important concept of clearance

 

Difference in radius between the two surfaces

- reducing clearance and producing an exact fit is worse

- creates equatorial contact with cold welding and seizure

 

Prefer controlled clearance 0.06-0.1mm

- creates polar contact rather than equatorial contact

 

New machining far superior

 

Wear 

 

Decrease wear

 

Reduced linear and volumetric wear

- initial run in perior then steady state

- linear wear < 0.003 mm / year

 

Reasons

- increase smoothness

- thicker film

- polar bearing not circumferential

 

Strict control over manufacture essential

- early failures due to poor manufacturing

 

Advantage

 

Very high wear resistance

- 1 / 60 of metal / poly

 

Large heads

- decreases dislocation / improves ROM / function

 

Disadvantages

 

Increased ion levels

 

Serum / blood / RBC / urine increased levels Co & Cr

- up to 500 times the number of poly particles per year

- tends to decrease with time

- effects unknown

 

Best to measure serum levels in Nmols/l

- range for well functioning implant is 15 - 30 for Co and Cr

- increasing levels or levels several time normal of concern

- can imply a failing implant

 

Carcinogenesis

- no evidence for this

- metal on metal follow up for 50 years (McKee-Fararr)

 

Delayed type hypersensitivity

 

Cause unknown

- lymphocyte reaction

- very rare (1/1000)

- may cause unexplained pain

 

Patient can get large inflammatory reaction

- can cause tissue destruction +++

- lose abuctors etc

- difficult salvage

 

AJR 7 years

 

Ceramic / Ceramic  3.9%

Metal / Poly             3.2%

Ceramic / Poly         4.1%

Metal / Metal           7.7% (Head sizes > 28mm)

 

 

Biomechanics

Introduction

 

Peak pressures during gait

- between heel strike and early mid stance

- increases in both JRF and abductor activity

 

Chair rising 

- triples pressures

 

Hip forces

 

Single Leg Stance / Free Body Diagram of the hip

 

Calculation

- force exerted by the abductors

- balance effective body weight acting on the head of the femur

- equal magnitude, opposite direction

 

Abductor muscle force

- both a horizontal and a vertical component  

- assumed to be oriented at 30° with respect to a vertical axis

- this adds to the forces across the hip

 

Problem

- only G medius tension is calculated 

- a gross oversimplification

- need to consider G max. & other muscles

- ground reaction force is under calculated

- GRF recorded in prosthetic femur is much higher than FBD would suggest

 

Forces

 

Body weight during one-legged stance 

- 5/6 BW (1/6 BW is weight of leg patient standing on)

- effective body weight will act in a vertical direction

 

Single leg stance 3x BW

Walk ~4x BW

Jog~ 6x BW

Stumble ~9x BW

 

Adbuctor lurch

 

Shifting the body weight over the centre of the hip joint

- eliminating the need for the abductors to balance body weight

- reduce joint reaction force

 

Impact of walking aids

 

Walking with cane in contralateral hand

- analytical and in vivo studies 

- clearly shown reduces the joint force

 

Mechanism

- moment arm of the cane is much larger than that of the abductor muscles

- lower muscle forces are now required to balance the effective BW moment

 

Implications of rotational moments

 

Longitudinally and posteriorly directed loads

- most critical in generating stem fractures

- most fractures start at the anterolateral corner.

 

Posteriorly directed forces

- occur when the hip is flexed

- result in retroversion of the stem

- may play a significant part in loosening femoral stems

 

Clinical implications of hip joint geometry

 

Mechanical ability of the abductors are affected by

- head-neck angle

- neck length

- joint centre position

 

Aims

- recreate centre of rotation

- decrease JRF

- increase offset

- Increase abductor strength

 

Joint centre

 

Joint forces are minimized when the joint centre is moved medially, inferiorly, and anteriorly

- maximizes the moment-generating capacity of the abductors 

 

OA displaces femoral head laterally, superiorly, and posteriorly

- largest joint forces and moments are generated in this position

 

Lateral and distal joint centre 

- decreases the abductor's moment arm 

- therefore preventing contralateral pelvic drop now requires an increased muscle force

- increases the joint's compressive force

 

Superior joint centre

- inferior functional outcome

- decreased abductor strength

- loss of passive hip flexion

- can compensate with increased neck length   

 

Higher contact force / increased wear and loosening

- superior and lateral joint centre

- decreased femoral offset

- decreased abductor moment arms 

 

Head Neck Angle

 

Varus hip

- decreased head-neck angle 

- increases the mechanical advantage of the abductors

- therefore should minimise joint contact forces

- also improves stability with increased congruence

 

Valgus Stem

- decreased bending moment or shear on stem

- increased axial stem loading

 

If excessive

- increases knee valgus strain

- lengthens limb

- superior dislocation

 

Varus Stem

- increases shear on neck

- decreases axial loading

 

If excessive

- shortens femur

- increases dislocation

 

Neck length

 

Decreasing the neck length 

- similar to increasing the head-neck angle (valgus) 

- compromise the abductor function and increase the joint reaction force

 

 

Cemented Exeter Technique

Cemented cup and femur via posterior approachTHR Cemented Exeter

 

Set up

- on side

- charnley supports posterior on sacrum

- anteriorly on ASIS

- patient slightly tilted backwards

- avoids cup retroversion

 

Posterior Approach

- identify short ER

- open interval between G medius and piriformis with scissors, insert anterior retractor

- do the same with inferior aspect of quadratus

- diathermy all visible bleeders now

- 2 x stay sutures in short ER with 1 ethibond, clip and cut

- take off short ER and capsule with diathermy, superior radial cut in capsule to labrum

- dislocate hip

- second running stay suture in capsule with Ethibond

 

Releases

- release posterior capsule from short ER to mobilise better as flap for repair

- release superior capsule from labrum, also anterior capsule from labrum delicately with knife

- place specific Exeter anterior retractor

- divide inferior capsule delicately with diathermy, leave inferior transverse ligament intact

- place rolled swab here, place inferior retractor

- anterior retractor is tied to charnley support with weight and chain

- inferior retractor has weight attached, supported by assistant

- insert Norfolk-Norwich retractor superiorly

 

Cup

 

Remove labrum

- identify floor by removing osteophyte / reaming medially /  or can use 2.5 mm drill and measure floor depth

- ream in increased sized until fits in AP diameter

- need to remove all cortical bone, can do so with smaller reamer

- many drill holes required superiorly, this is the area where good interdigitation is critical and important

- drill holes in ischium and superior pubic rami as per charnley

- dry acetabulum with swabs and peroxide

- place reamings with spoon at inferior acetabular ligament and compress, this prevents cement leaking inferiorly

- trial cup, can use cup with peripheral poly lip to pressurise, cut to size

- insert ball of cement when no longer sticky

- compress till 5 minutes, twist pressuriser to remove

- dry blood with swab on a stick

- insert cup on insertion device

- place inferior cup first, medialise +++, then set closure and anteversion

 

Avoid

 

THR Cemented Exeter Inferior Cement LeakTHR Cemented Cup Excessively OpenTHR Cemented Exeter Medial Cement Penetration

 

Femoral Stem

 

Femur

- held vertical by assistant

- fish mouth elevator to elevate femur

- gluteal retractor holds gluteals

 

Entry point

- box chisel

- start lateral and posterior

- follow bow of femur

- pass 2 x reamers

- find centre of femur

- check not perforating femur 

 

Incremental increase in broaches

- leave some cancellous bone

- allows cement interdigitation

 

Orientation

- anatomical anteversion 15°

- in neutral or slight valgus

- >5° varus increases failure

- line up with patella as insert

 

Trial

- offset

- neck length

- head size

- check stability and LLD

 

Cement

 

1st generation 

- all by hand

 

2nd 

- plug, lavage, retrograde fill   

 

3rd 

- vacuum centrifuge, pressurisation 

 

Technique

- cement restrictor 1 cm beyond tip

(makes easier to get out if needed)

- wash cancellous bone with water

- H2O2 gauze (lyses RBC), suction

- vacuum centrifuge Abx impregnated high viscosity cement

- baby suction catheter

- retrograde filling with cement gun

- fill at 1 minute

- pressurisation til fat emerges (warn anaesthetist)

- slow insertion stem at 4 minutes, follow lateral wall

- clean cement away

- maintain constant pressure til hard

 

Retrial

- ensure stability / LLD

- apply definitive head

 

Closure

- capsule and ER sutures passed through drill holes in GT

- use suture passer

 

Clinical History

History

 

SOFI

 

Symptoms

Other joints / other specific

Function

Interventions (surgery, physio, injections)

 

PMHx / PSHx / Meds / Allergies

 

Social History

- occupation

- dwelling

- smoking / alcohol

 

Symptoms

 

"What is your problem?"

 

PAIN (NILDOCARP)

 

Nature (Sharp or Dull)

Intensity (1-10)

Location - point for me?

Duration - how long?

Onset

- specific details of injury ?

- rest / night / start-up

Concomitant Factors 

- locking / clicking / swelling

Aggravating Factors

Relieving Factors

Radiation

Pattern / frequency

 

Associated symptoms

- leg lengths

- stiffness

 

Causal factors 

- AVN -> steroids, alcohol, RTx / CTx

- RA / other inflammatory conditions

- CDH / DDH / SUFE / Perthes

 

Other joints

 

Knee / Back

Signs inflammatory condition

 

Functional Assessment

 

Lower limb (Modified Harris Hip Score)

1.  Shoes & socks

2.  Stick / Walking aid

3.  Limp

4.  Stairs

5.  Walking time/distance

6.  Public transport / In or out of Car?

7.  Run or Squat if young adult

8.  Prop at speed if sportsman

 

Little old lady gets out of bed, puts her shoes on, picks up her stick, & limps to the door

- climbs down the stairs, walks two blocks to the bus, & pushes over the jogger doing squats

 

Disability

"What can't you do that you used to be able to do?"

 

1.  Occupational

2.  Recreational - sports, hobbies

3.  ADL's

- recreational

- showering / toileting / cooking / shopping

 

Interventions

 

ELMPOPI

 

Education

 

Lifestyle modification

- weight loss

 

Physio

 

Orthotics - stick

 

Pharmaceuticals

- symptomatic (NSAIDS, narcotics)

- disease modifying (steroids, anti-rheumatoid)

 

Injections

 

 

Fixation

Background

Cemented Acetabulum

IndicationsTHR Cemented Acetabulum

 

Neoplastic / metastatic

Severe osteoporosis

Pagets

 

Longetivity

 

Ranawat 

- longevity directly related to quality of cement penetration into acetabulum

 

Types

 

Reflection all Poly (S&N)

Exeter all Poly (Stryker)

Zimmer ZCA

 

Cemented ZCA cup

 

Pathology

 

Retrieval studies from successful THR's

- fibrous membrane found at least in part

- begins at periphery of bone-cement interface 

- mechanical testing shows the most stable are those with least membrane

 

Metal Backing

 

Theory that more rigid implant construct could more evenly distribute stresses to surrounding acetabulum 

- cement & subchondral bone would be protected from fatigue failure

 

Actually perform poorly compared with all poly

- reasons for inferior clinical outcomes not well understood

- accelerated wear of polyethylene suggested as cause

 

Loosening

 

Process of loosening may be result of cellular rather than mechanical process

- determined by host reaction to polyethylene debris

 

Signs

- obvious migration in comparison previous films

- cement mantle fracture

- progressive > 2 mm lucency cement / poly interface

(c.f. cement-bone interface)

 

Charnley & De Lee - 3 zones

1 - superior 1/3

2 - middle 1/3

3 - inferior 1/3

 

Cemented Cup 3 Zone LysisCemented Cup Lysis Zone 1

 

Results

 

AJR 2010

 

9 year

 

Exeter / Contemporary   6.0%

Exeter / Exeter              4.9%

Spectron Reflection        9.0%

MS30 / Low Profile Cup  1.7%

 

CPT / ZCA 7 year            %2.9

 

 

Cemented Femur

THR Cemented Femur

Goals in femoral cementing

 

Optimize cement-bone interface

Cement mantle free of defects

Minimum 2 mm thickness

Femoral component centred in cement mantle

 

Survival

 

Swedish Joint Registry

 

Reflection All Poly / Spectron 92% 10 year

 

Exeter All Poly / Exeter 93% 14 year

 

Surface

 

1.  Polished

- Ra less than 1 micrometer

- polished stems create little abrasion

- allow subsidence and keep cement in compressive loading 

 

2.  Matte 

- Ra less than 2 micrometer

- matte finish will not create excessive abrasion unless stem allows large micromotion 

- allows some mechanical interlock with cement

 

3.  Rough 

- Ra greater than 2 micrometer

-  expected to cause excessive abrasion

 

Studies have shown increase aseptic loosening and revision rate with matte finish

- failed ~10% at 10 years

- c.f. 4% at 20 years for polished

 

Reason

 

Creep is time dependent deformation

- creep of cement is related to age

- creep at 1 day is 3.25 x at 7 days

- creep allows stabilization

- cycles of creep, followed by stress relaxation leads to stem subsidence in the mantle

- Matte finish prevented subsidence

 

Collar

 

Controversy exists over the use of collared prosthesis

- results in increased load transfer from implant to proximal femur compared to collarless implants

 

A.  May reduce stress shielding of proximal femur & reduce strain in proximal medial cement mantle

 

B.  Prevents subsidence

 

Exeter stem 

 

Behaves as a Morse taper in the cement mantle

- transmits both torsional & compressive loads

- generates hoop stresses in the cement which allows it to expand slightly

 

Characteristics

 

1.  Smooth polished surface

- no sites of stress concentration

 

2.  Broader laterally than medially 

- helps to diffuse the compressive stress medially 

 

3.  Tapered shape from proximal to distal 

- allows controlled subsidence within the cement column; 

 

4.  Cobalt-chromium alloy stems 

- are used in most stems

- generate less particulate debris than titanium implants

 

5.  Triple taper concept

- femoral component tapers to a point in both the AP and lateral planes

- in addition, the stem is more narrow medially and widens laterally

 

Advantage low porosity cement

- Cement fails in fatigue

- Centrifugation decreases pore size in cement 

- approximately 200 to 400 nm in diameter 

- results in an increase in cross-sectional area

- 25% increase in ultimate tensile strain 

- 125% increase in tension-compression fatigue strength  

- Similar benefits demonstrated with vacuum mixing

 

Cement Issues

 

Cement viscosity

- in vitro and in vivo tests 

- structural superiority of high viscosity over low viscosity cement

- i.e. Simplex (highly viscous) v Palacos (low viscosity)

 

Pressurisation

- strength of cement-bone interface directly related to depth of penetration of cement into bone

- pressurization increases penetration

 

Centralisers 

- achieve more uniform cement mantle 

- especially zone 5 & 6

 

Cement Mantle

 

Ideal cement mantle thickness has not been defined

- autopsy studies - crack incidence greatest when mantle < 2 mm

- issues with the varus stem

 

Varus stem 

- associated with higher incidence of aseptic loosening

- results in thin or nonexistent cement mantle in proximal medial & distal lateral zones

 

Antibiotics 

- in relatively small doses effect on mechanical characteristics of PMMA negligible

- must be heat labile

- vancomycin / tobramycin / gentamicin

 

Cementing techniques

 

First-generation 

- finger-packing doughy cement 

- no cement restrictor

 

Second-generation 

- cement restrictor

- cleaning with pulsatile lavage  

- cement inserted retrograde using cement gun 

 

Third-generation 

- vacuum centrifuge (reduce porosity)

- pressurization of cement mantle 

- surface modifications on implants 

 

Fourth-generation 

- stem centralization proximal & distally

- ensure adequate & symmetric cement mantle

 

Barrack grading system for cement technique

 

Aseptic loosening correlates with cement technique

 

A. Complete filling of proximal portion of diaphysis 

- difficult to distinguish cortex from cement

- commonly referred to as "white-out"

 

THR Type 1 Cemented Femur

 

B. Near complete filling of diaphysis 

- can distinguish cortex from cement in some areas

 

Type 2 Cemented Femur

 

C. Divided into C1 & C2

 

C1

- Incomplete cement mantle in proximal portion

- > 50% of cement-bone interface demonstrates radiolucencies

 

THR Type 3 Cemented Femur

 

C2

- Mantle < 1 mm thick or metal is up against bone

 

THR Type 3b Cemented Femur

 

D. Cement mantle with gross deficiencies 

- no cement below the stem, major defects in the mantle, or multiple large voids in the mantle

 

Failure

 

Endpoints 

- need for revision surgery

- clinical failure (a painful arthroplasty)

- radiographic failure (loose implant)

 

Mechanisms of Failure

 

Mechanical factors

- debonding between stem & cement initially occurs at cement-metal interface

- produces high peak stresses in cement mantle proximally & near distal tip of stem 

- initiates cement cracks esp areas of thin cement / adjacent to mantle defects / pores initiate & propagate 

 

Biologic processes 

- then become more important

- particulate polymeric debris gains access to endosteal bone

- stimulates foreign-body reaction 

- bone resorption with fibrous tissue membrane beginning at pseudo-capsule extending along cement-bone interface

 

Harris Categories 

 

"Definitely loose"

- migration of prosthesis

- cement mantle fracture

 

Cemented Femur Definitely Loose

 

"Probably loose" 

- continuous radiolucent line at cement-implant

 

Cemented Femur Probably Loose

 

"Possibly loose" 

- radiolucent line cement - bone

 

Cemented Femur Possibly Loose

 

Autopsy studies 

 

Radiolucencies most commonly related to skeletal remodelling

- not to the formation of soft-tissue membrane between cement & bone

- inner cortex commonly forms adjacent to cement mantle

- not distinguishable from cement on Xray

- 2nd medullary canal forms between inner & outer cortex 

- appears as radiolucency on Xray

- non-progressive

 

Uncemented Acetabulum

GoalTHR Uncemented

 

Initial mechanical stability

- adequacy of locking between component and bone

 

Need initial press fit for mechanical stability

Long term require biological fixation

 

Advantage

 

Can change liner

- multiple revision options i.e. for dislocation

 

Simple to remove

- Zimmer Xplant

 

Design

 

1.   Smooth

- relied on mechanical interlock for stability and long term fixation

- unacceptable early revision rates

- initial press fit, but no biological fixation

 

2.  Threaded

- universally bad results

- due to small contact area between bone and implant

 

3.  Smooth HA coated

- improved but still inferior results

 

4.  Porous coated

- allows ingrowth

- much better results compared to smooth components

- titanium or HA

 

5.  Hemispherical

- oversized cup

- initial press fit

 

6.  Flattened hemispherical

- rim fit

 

Requirements

 

1.  Material must be biocompatible

- titanium mesh

- cobalt chromium beads

- HA

- all of these materials have been shown to be adequate provided pore size is correct

 

2.  Surface must have optimal pore size

- between 100 and 400um

 

3.  Component must be placed in intimate contact with viable host bone

 

Press fit

- < 0.5 mm gaps 

- require tight peripheral press fit with complete seating

- maximises surface are available for ingrowth

- maximises area for stress transfer

 

Technique

- 1-2 mm underream

- risks are acetabular fracture and underseating

 

Acetabular Underseating

 

4.  Adequate initial stability to allow reliable ingrowth

- micromotion > 40 um generates fibrous tissue 

 

Options

- press fit with supplemental screw fixation

- line to line reaming with supplemental screws

- spikes

- pegs

 

Supplemental screw fixation

- 2 x bicortical screws

- provide similar stability as press fit

 

Uncemented Cup with screws

 

Screw problems

- can get backside wear / fretting

- holes can provide route for particle wear

 

Technique Uncemented Cup

 

Centre reamer in desired hemisphere of acetabulum

- begin 6 - 10 mm below templated size (44)

- medialise initially

- remainder reaming in direction of final component position

- 45o abduction

- 20 - 30o abduction

- increase until contact anterior and posterior

- AP diameter is what determines cup size

- petechial bleeding

- don't take away all subchondral bone

- continually assess posterior / anterior walls - must preserve

 

Can bone graft base and reverse ream

- especially with flattened hemisphere

 

Insert component 1 - 2 mm larger

- ensure seating (remove insertion handle and probe base)

- ensure stability

- add screws if any doubt

 

Screw placement

 

 Acetabulum Wasielewski Safe Zones

 

Wasielewski et al JBJS 1990

- anatomical cadaveric study

- line ASIS to centre acetabulum & ischial tuberosity

- line perpendicular to this 

- four quadrants 

- safe quadrants = 2 posterior quadrants

- posterior screws do not emerge within pelvis

 

Structures at risk

 

AS quadrant

- external iliac vein > artery

- vessels can be within 0.5 cm of the inner cortex of the pelvis

- become closer with increasing age

- in the anterior quadrants 25mm screws often too large

 

AI quadrant

- obturator nerve & vessels

- femoral artery 

 

PS quadrant

- sciatic nerve / superior gluteal nerve & vessels in danger at greater sciatic notch

- aim screw between 2 cortices of ilium

- direct towards SIJ

- can tolerate 85 mm

 

PI quadrant

- internal pudenal vessels

- inferior gluteal nerve & vessels

- maximum screw length is 25 mm

 

Complications

 

Acetabular fracture

 

Increased risk

- > 2 mm underream

- acetabular sizes < 52

- elderly (consider line to line reaming and use of screws, or use cement)

 

Management

- screws

- posterior column plating

- cage

 

THR Uncemented Cup Acetabular Fracture

 

Failure of liner fixation / acetabular fixation

 

Acetabular spin out

- insufficient initial fixation

- failure biological fixation

 

THR Uncemented Cup Spin out

 

Liner spin out

- must ensure fixation method is sufficiently engaged

 

Errant Screw placement

 

Anterior quadrants

- can cause catastrophic haemorrhage

 

Management

- angiogram  / embolism

- laparotomy / pelvic packing

 

Loosening

 

Loosening Uncemented Cup

 

Can be very difficult to identify with uncemented acetabulum

 

 

 

 

Uncemented Femur

GoalTHR Uncemented

 

Initial press fit

- implant geometry fits the cortical bone in the proximal femur

- good initial mechanical stability

 

Biological fixation for success

- good press fit

- minimal micromotion

- bony or fibrous tissue ingrowth or ongrowth

 

Longetivity

- avoidance adverse stem bone stiffness ratios

- fixation surface that provides a transitional stress transfer from the proximal femur to the diaphysis

- avoid extreme stress shielding or excessive rigidity

 

Press fit

 

True Press-Fit in Bone 

 

Bone is a viscoelastic material

- implies that its elastic recoil will become less with time

- the amount that bone will "creep" or undergo stress-relaxation depends on its density

- cortical bone has less viscoelastic behavior than cancellous bone

- the fact that bone will relax and lose elasticity over time limits the amount of time over which a true press-fit can be maintained in bone

- once the initial press-fit dissipates,a prosthesis may move under load in the bone and either re-establish a press-fit or become loose

 

Non porous coated uncemented implants are commonly referred to as press fit implants

 

Design

 

Proximal metaphyseal filling

- curved, anatomic stem

- most common

- tight proximal fit

 

Distal isthmus filling

- straight stem

- used more commonly in revision

 

Techniques of Initial Fixation

 

Definition Rigid Fixation

- micromotion <150 microns

- ideal 50-100

 

A.  'Press fit' (1-2mm undersized) technique

- bone expands around prosthesis

- generates hoop stresses

- femur and acetabulum

 

B.  Line to line fit

- bone is prepared to same size as implant

- extensive porous coating with stem

 

Contraindications

 

Stove pipe femurs (Dorr < 0.75)

Poor bone stock

 

Proximal femoral geometry / Dorr calcar-to-canal ratio

 

Important if considering uncemented prosthesis

 

3 types - 501's, Stove pipe, Flares

- measure canal at LT & 10cm below 

- inner diameter at midportion of LT divided by diameter 10 cm distal

- must be <75% for uncemented prosthesis

 

Type A 

- ratio < 0.5 

- cortices seen on both AP & lat

- most amenable to uncemented component

 

Dorr A Femur

 

Type B 

- between 0.5 and 0.75 

- thinning of post cortex on lateral

- intermediate

 

Dorr B Femur

 

Type C 

- > 0.75 

- thinning of cortices on both views 

- "stovepipe" femur

- favours use of cemented stem

 

Biologic fixation

 

Two types

 

1.  Ingrowth 

- porous coating

- HA coated

- combinations

 

2.  Ongrowth 

- grit blasted

- increases roughness

- typically needs to be entire surface 

 

Ingrowth

 

Pore size

- optimum pore size 50-350 microns (ideal 50-150)

 

Porosity

- 40-50%

 

Pore depth

- deeper pores better

- increased shear strength with loading

 

Mechanism of porous coating

 

Titanium plasma sprayed

- often used to create pores

- then covered with HA to supplement

 

Tricalcium phosphate

- also used

 

HA coating

- sprayed on as a porous coating

- osteoconductive

- surface dissolution to Ca and Phosphate

- stimulates osteoblasts

 

Extent of Porous coating

 

Complete / incomplete

- both proximal and distal fixation are important

- is a trade off between fixation and shielding

 

Extensively coated implants

- improve likelihood of solid fixation

- distal loading of bone

- get mainly diaphyseal spot welding

- increase proximal stress shielding

- same problem with cemented implants

 

Femur Fully Coated Proximal Shielding

 

Proximal porous coating

- proximal loading of bone

- minimises proximal shielding

- more common

 

Materials

 

Rigidity

 

Want less rigidity to minimise stress shielding

 

Stiffness related to 

- modulus

- fourth power of the stem radius

- solid v slotted / fluted stems

 

Young's modulus of Elasticity

 

Bone 12

Titanium 117

Cobalt-chromium 210

 

Minimise rigidity

 

1.  Titanium alloy v cobalt chromium

- less structural rigidity

- lower modulus of elasticity

- 2 - 3 x less stiff

 

2.  Implant size

- as size increases, rigidity increases

 

3.  Design

- some stems have a coronal slot to decrease rigidity

 

Osteointegration

 

Engh et al categories

 

1.  Osseointegration

2.  Stable Fibrous ingrowth

3.  Unstable fixation

 

A.  Signs of osteo-integration

 

Take 1 year to see

 

1.  Spot welds

- densification of endosteal bone

- usually in the region of termination of the porous coating on the implant

 

THR Spot Weld

 

2.  Absence of any radiodense reactive lines

- may occur around the smooth portion of the implant

- this is where bone ingrowth is not expected to occur

- they should not be present adjacent to the porous coating

 

3.  Calcar atrophy

- this change is sometimes subtle

 

4.  Increased cancellous density / cortical hypertrophy distal to the coated region

 

B.  Failed bone ingrowth / successful stabilization by fibrous tissue ingrowth 

 

1. Parallel Sclerotic lines 

- remodelling signs around the porous surface 

 

2.  Less atrophy of the medial femoral neck

 

2.  No progressive migration 

 

3.  No local cortical hypertrophy / spot welding

 

C. Signs of frank implant instability 

 

1.  Component migration

- usually by subsidence and varus tilt

 

2. Progressive luceny on serial radiographs

 

3.  Development of inferior pedestal

 

THR Subsidence Uncemented Component

 

Complications

 

Fracture

- slow careful insertion / make sure is advancing with each blow

- can prevent or treat with cerclage wire

- assess stability

- revert to cemented stem if unable to obtain stability with press fit

 

Uncemented Femur Intraoperative Fracture

 

Thigh pain

 

Causes

 

1.  Initial instability (lack of press fit)

2.  Failed bony ingrowth / Late instability

3.  Micromotion at distal stem

- disadvantage of proximal coating

- will usually resolve over 2 years

- only 1% severe pain

4.  Mismatch modulus of elasticity

- lower with titanium

- tend to have lower incidence of thigh pain

- smaller stems

5.  Osteoporotic bone

 

Treatment

- can cerclage wire cortical strut grafts

- improve bony rigidity over distal stem

 

Stress shielding

 

Most common with distal press fit / fixation

 

THR Proximal Stress Shielding

 

Osteolysis

Head size

THR Large Head

Issues

 

Wear

Stability

Normal feel of hip

Increased ROM

 

Wear

 

Large head

- increase volumetric wear

- less penetrative / linear  wear

 

Small head

- increased linear wear

- decreased volumetric wear

 

Livermore's studies showed

- 32mm highest volumetric wear

- 22mm highest linear wear

- determined 28 mm optimal size

 

High volumetric wear in metal on poly generates high levels of particles stimulating osteolysis

 

Stability

 

Head size affects dislocation because of two variables

 

1.  Primary arc range

 

Distance head can move before impinging and levering out

 

Increase by

A.  Increasing head:neck ratio - increases the primary arc range

B.  Tapering neck

C.  Modifying rim of cup

 

2.  Excursion distance

 

The distance the head must travel in order to dislocate once the neck begins to impinge

- jump distance

- half head diameter

 

Problem

 

Large head size does not exclude dislocation

 

THR Dislocated Birmingham

 

Methods to increase head size

 

Ceramic on ceramic

- size currently limited

- maximum is 36 mm alumina heads

 

Metal on metal

- potentially decrease wear with increased size

- due to improved fluid film and boundary lubrication

 

Australian Joint Registry 2010

- increased revision rates with metal on metal

- most evident with larger sizes > 32 mm

- many company's prosthesis, not just one

- especially in females and younger patients

 

Metal on highly cross linked poly

- increased wear resistance

- can use thinner liners

- able to use larger heads

 

 

 

Offset

Definition

 

The perpendicular distance from the centre of the femoral head to the long axis of the femur

 

Harris 1992

- aim for supra-physiologic offset 

- avoid making offset less than original at all costs & makes longer if possible

 

Soft tissue balancing equals restoring femoral offset

 

Effect of short offset

 

1.  Abductor lurch / Trendelenburg gait

2.  Increased JRF / increased wear rates

3.  Weak abduction increases O2 consumption

4.  Impingement

5.  Lax soft tiiues can cause dislocation

 

Decreased offset leaves the abductors lax  

- doing so means they have to act with increased force

- increases the joint reaction forces across the hip.

- rsult of this is increased wear rates

 

Sakalkale et al Clin Orthop 2001

- 17 patients bilateral THR

- one STD, one high offset

- liner wear 0.21mm c.f. 0.01 mm /year

 

Increased offset

 

Advantage

- decreases JRF

- tightens lax abductors

 

Disadvantage

- theoretical increase in torque forces on stem and cement in flexion

- cadaver studies demonstrate increased offset doesn't increase torque forces on cement & bone

- torque increased in the stem but it is below the fatigue threshold modern stems

 

Factors affecting offset

- neck shaft angle

- head neck length

- anteversion

- femoral osteotomy level

- position of acetabulum

 

How to increase offset

 

1. Decreasing neck shaft angle

- more varus neck shaft angle

- increases torque on implant

 

2. Increasing Head /  Neck length

- improves abductor tension

- worsens LLD

 

3.  Medialising femoral neck whilst lengthening femoral neck

- technique in high offset stems

- maintains neck shaft angle

 

4.  Advancing GT

- increases abductor offset

 

5.  Acetabular component

 

Lateralised liners

- increase offset whilst preserving leg length

- can worsen body weight lever arm

- do so only when increasing femoral offset insufficient

 

Medialising centre of rotation

- decreases offset

 

Checking Soft Tissue Tension and Offset

 

1.  Preoperative templating

- normal side

- aiming to reproduce normal biomechanics

 

A.  Limb length

B.  Acetabular component

C.  Femoral component

 

2. Intraoperative measurement

 

Measurement jigs

- 2 fixed reference points

- limb in consistent position

- measure length and offset

- usually pin in supra-acetabular area

- second in GT

 

3.  Intraoperative maneuvers

 

Shuck test

- distraction of hip joint with in line traction

 

Dropkick test

- hip extended, bend knee to 90o

- if too tight, RF is taut and passively extends the knee

 

Leg to leg comparison

- feel knees when legs is similar positions

- feel tension of abductors

 

Rotation

- external rotation in extension

- flexion

 

 

Templating

AimTHR Templating

 

Reproduce the normal anatomical centre of rotation

Restore femoral offset 

Maintain equal leg lengths 

 

Usually template off normal hip

 

Template

 

1. LLD

2. Offset

3. Femoral component

4. Acetabular component

5. Osteotomy / femoral seating

 

Require

 

AP pelvis

- hips internally rotated 10-15o

- accounts for anteversion

- allows true neck shaft angle

- otherwise will underestimate true femoral offset

 

AP centred femoral head

 

Lateral hip joint

- used for planning location of proximal femoral opening in the piriformis fossa

 

Magnification

- product of distance between pelvis and film

- increased in obese patients

- less in thin patients

- can use magnification marker which is know to be 10 cm

 

Leg Length

 

1.  Horizontal line through two points at inferior aspect of ischial tuberosities

- compare to lesser tuberosity

 

THR Minimal LLD Template

 

2.  Acetabular teardrop

- vertical line to centre of femoral head

- calculate difference

- multiply by 0.8 to account for 20% magnification

 

THR Template Severe LLD

 

Tear drop more reliable

- less affected by rotation

- closer to centre of rotation of hip

 

Note: ensure one femur is not abducted, adducted

 

Acetabular component

 

THR Template Acetabulum

 

Always template before femoral component

- establish centre of rotation

 

Technique

 

Establish landmarks

- line through teardrops

- ilioischial line

- superolateral margin of acetabulum

 

Position

- apex just lateral to the teardrop

- medial border just lateral to ilioischial line

 

Orientation

- 45o relative to horizontal plane

- 20o anteversion on lateral x-ray

- sufficient superolateral cover

- reproduce any uncovering intra-operatively

 

Mark centre of rotation

 

Specific cases

 

1. Protrusio

- template to teardrop and ilioischial line

- ream only to obtain adequate peripheral support

- calculate amount of medial bone graft

 

2.  Medial osteophytes / lateralised cup

- again template from teardrop / ilioischial line

- ream medially

- ensure same amount of superolateral coverage as with templating

 

3.  Dysplastic acetabulum

- insufficient acetabular coverage

- superolateral migration of femoral head

- restore hip centre

- calculate SL uncoverage

- if sufficient posterior wall and only uncovered anterolateral bone graft not required

- otherwise augment with femoral head / high hip centre / augmented cups

 

Femoral component

 

THR Template Femur

 

Aim

- template size

- calculate LLD / neck cut

- restore offset

 

X-ray

- AP with femur internally rotated 20o

- puts true neck shaft angle in plane of film

 

Component size

 

Cemented

- 2 mm cement mantle

 

Uncemented

A.  Proximal coated / metaphyseal fit

- optimal medial and lateral endosteal cortical fit of proximal femur

B.  Fully porous coated

- optimal endosteal contact in diaphyses

- 4-5cm of scratch fit

 

LLD / Femoral Osteotomy

 

Calculate LLD

- place centre of femoral component measured amount above centre rotation

- mark neck cut

 

Offset

 

If femoral head medial to centre of rotation

- offset is increased and this will decrease JRF

 

If femoral head lateral to centre of rotation

- offset is decreased / avoid

 

 

 

Trochanteric Osteotomy

Types

 

1.  Standard trochanteric osteotomy

2.  Sliding trochanteric osteotomy

3.  Extended trochanteric osteotomy

 

Standard Trochanteric osteotomy

 

Standard Trochanteric OsteotomyStandard GT Osteotomy Wire Fixation

 

Concept

- detach GT with only abductors attached

 

Indication

- increasing exposure to acetabulum in difficult cases

- retensioning abductors

 

Problem

- difficulty fixation / unstable

- most hip surgeons now use sliding osteotomy

 

Technique

- detach proximal attachment of vastus lateralis

- pass retractor deep to G medius / minimus and superficial to capsule

- saw osteotomy from lateral aspect of GT angled up towards retractor

- detach any short external rotators and reflect superiorly

 

Fixation

- 3 - 4 intraosseous wires

- claw plate

 

GT Osteotomy Plate Fixation

 

Modification / Chevron Osteotomy

- increased stability

- decreased non union

 

Complications

- non union

- migration

- wire breakage / painful hardware

 

GT Osteotomy Broken WiresGT Osteotomy Broken WireGT Osteotomy Failed Plate

 

Trochanteric Slide

 

Concept

- PA osteotomy

- vastus lateralis and G medius left attached to fragment

- fragment retracted anteriorly

 

Advantage

- increased inherent stability

- vastus lateralis prevents proximal migration

 

Technique

- retractor superiorly deep to minimus and superior to capsule

- posterior elevation of vastus lateralis

- retractor under vastus lateralis insertion

- oscillating saw anterior to posterior

 

Fixation

- wires

- grip plate

 

Extended Trochanteric osteotomy

 

Concept

 

Osteotomy lateral 1/3 to 1/2 of trochanter & femur

- posterior to anterior longitudinal cut

- short distal transverse cut

- levers / hinges open anteriorly

- maintains anterior vasculature / muscle attachment

 

Indications


1.  Aid exposure
2.  Removal cement (especially infection)
3.  Removal well fixed uncemented prosthesis
4.  Removal cement plug / bone very poor / risk of perforation high
5.  Abnormalities of the proximal femur


Contraindications / Relative


1.  Impaction bone grafting
2.  Cementing revision prosthesis

 

Technique ETO
 

Length
- measured from tip GT
- 2 – 15 cm long

- determined from preoperative template
- need to preserve diaphysis if using distal press fit uncemented stem


Timing
- usually after implant removal
- may not be possible


Site
- elevate vas lateralis forward
- expose linea aspera
- expose posterior femur


Osteotomy
- use drill holes to mark osteotomy

- drill both cortices
- thin oscillating saw
- cut down through anterior and posterior femur in line with GT
- through both cortices
- transverse cut distally through 1/3 diameter
- lever open


Fixation
- 3 x cerclage cables
- protect sciatic nerve / palpate / pass wires posterior to anterior
- submuscular

 

Results
 

98 – 100% union rate by 6/12

 

 

THR Resurfacing

ConceptBirmingham Hip Resurfacing

 

Femur

- removal of femoral head cartilage

- resurfacing with metal

- cemented / uncemented

 

Acetabulum

- standard technique

 

Bearing surface

- metal on metal

 

Indications

 

Relatively young man (40 - 50)

OA

 

Absolute Contra-indications

 

Severe bone loss femoral head

Large femoral neck cyst

Small acetabulum

 

Relative Contra-indications

 

Osteoporosis

Age > 65

BMI > 35

 

Caution

 

RA

Female

AVN femoral head

 

Advantages (many theoretical)

 

1.  Bone preservation

- preserves femoral bone stock

- however makes acetabular preparation more difficult

 

2.  Improved stress transfer to proximal femur

- less proximal stress shielding

- improved proximal bone density

 

3.  Reduced dislocation rates

- heads 36-54 have reduced rates compared with 22-32

- can occur though if poor technique or component loosening

 

Dislocated Birmingham Hip ResurfacingDislocated Birmingham Resurfacing

 

4.  Better kinetics

- faster walking speeds

- may be better ROM

- possible better proprioception

- may be element of selection bias (i.e. is done in younger, fitter patients)

 

4.  Easier revision of femoral component

- better bone stock

- simply recut and use stem

 

6.  Possible improved longetivity

- very low wear rates metal on metal

 

Disadvantages

 

1.  Poor modularity

- difficult to adjust LLD

- difficult to adjust offset

- patients with very abnormal abnormality better off with conventional THA

 

2.  Not suitable for elderly / poor bone stock

- increased risk femoral neck fracture

 

3.  Femoral neck fracture

 

 

4.  Metal ions

- in serum, RBC, urine

 

Problems

- risk metal sensitivity

- risk carcinogenesis / teratogenesis

- CI in woman of child bearing age

 

5.  Loosening

 

Complications

 

Femoral Neck Fracture

 

Incidence 0-4%

- 1.5% in a study of 3500 BHR in Australia (JBJS Br 2005)

- early in learning curve

- early in prosthesis life

 

Risk Factors

- decreased bone mass / osteoporosis

- elderly

- inflammatory arthritis

- females (risk x2)(AJR)

- femoral head and neck cysts

- femoral neck notching

- varus femoral component (< 130o neck shaft angle)

- cup impingement on neck

- improper implant seating

- AVN femoral Head

 

BHR femoral neck notchingBHR Femoral Neck Notching 2

 

Revision

- relatively simple

- recut neck

- femoral implant with large metal head

 

Revision BHR

 

Early loosening

 

Machining

 

Initially due to poor early manufacturing

- decreased clearance

- inadequate polar bearing

- increased peripheral bearing, seizing, cold welding and loosening

 

Modern machining

- small surface asperities

- improved fluid film lubrication

- polar bearing with small clearances

- very low wear and little particle production

 

Causes

 

A.  Oversized heads / notching

 

BHR Oversized Femoral HeadBHR Loosening

 

B.  Varus Femoral Component

 

BHR Valgus v Varus Femoral Component

 

C.  Femoral head AVN

 

Due to extensive releases required to expose / surgically dislocate femoral head

 

BHR Femoral Head AVN

 

D.  Open Acetabular Component

 

Theorised to cause point loading

- increased metal wear

- best to close cup

 

BHR Open v Closed Acetabular Component

 

E.  Other

 

BHR Acetabular Component Protrusio

 

Australian Joint Registry 2010

 

13 300 procedures

 

Best outcome

- male < 65 with OA

- able to get > 50 mm head size

- 3.9% 9 year

 

Revision rate

 

Cumulative

- 7.2% 9 years for OA

 

Birmingham Resurfacing

- 6.2% 9 year

 

Reasons for revision

- fracture 36%

- loosening 33%

- metal sensitivity 7%

 

Revision by diagnosis 7 years

- OA 5.8%

- DDH 14%

- AVN 6%

 

Revision by prosthesis

- BHR 96.5% 5 year

 

Revision by age 7 years

- < 55     5.6%

- 55 - 64  5.8%

- > 65     7.3%

 

Revision by sex 7 years

- male 4.5%

- female 9.3%

 

Revision by head size 7 years

- < 44mm:    13.8%

- 45 - 49mm: 8.8%

- 50 - 54mm: 3.7%

- > 55mm:     2.2%

THR Revision

A Osteolysis and Loosening

DefinitionRevision THR Osteolysis

 

Biological response to particulate matter

- characterised by periprosthetic osteolysis

- stimulated by wear debris

- debris gains access to any area accessible by fluid

 

Sources of particulate debris

 

1.  Wear

 

Mechanisms of wear

A.  Adhesion

B.  Abrasion

C.  Fatigue

 

Modes of wear

 

1.  Motion between 2 surfaces designed for motion

2.  Primary bearing surface against an non intended bearing surface

- i.e. femoral head against acetabular shell when liner has worn out

3.  Interposed third body particles i.e. bone or cement

4.  Two non bearing surfaces together i.e. back sided fretting, morse taper fretting, screws

 

2.  Corrosion

 

Electrochemical process releasing metal ions

- modular interfaces i.e. head neck

- metal on metal bearings

 

Types of wear particles

 

Polyethylene

PMMA

Cobalt alloy

Titanium alloy

 

Morphology of wear particles

 

Usually less than 1um in size

 

Biological response to wear particles

 

Small particles phagocytosed by macrophages

- unable to digest

- stimulate release of cytotoxic factors

- TNF

- aggregates more macrophages

- release TNF, IL1, IL6, PGE2

- stimulated osteoclastic bone resorption

 

Poly wear

 

THR Poly WearTHR Eccentric Poly Wear

 

Lucent Zones

 

Gruen Zones

 

Femur:  Gruen Zones

 

AP 1-7

Zone 1:   Greater trochanter

Zone 4:   Tip

Zone 7:   Lesser trochanter

 

Lateral 8-14

Zone 8:   Anterior-superior

Zone 11: Tip

Zone 14: Posterior-superior

 

Charnley Zones

 

Acetabulum: Charnley Zones

 

Zone 1:  Superior 1/3

Zone 2:  Middle 1/3

Zone 3:  Inferior 1/3

 

Loosening

 

Concepts

 

1.  Easier to identify loosening in femur than acetabulum

- femur 90% accuracy

- acetabulum 65% accuracy

 

2.  More difficult to identify in uncemented prosthesis

 

3.  Lucent lines don't necessarily represent problem

- may be present in well-fixed prosthesis (retrieval studies)

- often due to remodelling 

 

Cemented Femur

 

Signs of cemented femoral component loosening

O'Neil & Harris JBJS Am'84

 

1.  Possible

 

Bone-cement lucency < 50% total

- may be due to poor cementing technique

- loosening if progressive

 

Cemented Femur Possible Loose

 

2.  Probable

 

Cement-implant radiolucent line >2mm wide

- progressive

 

Cemented Femur Probably Loose

 

3.  Definite

 

1.  Cement fracture

2.  Femoral stem fracture

3.  New lucency cement - implant interface

4.  Stem migration 

 

THR Probably LooseTHR Exeter Stem Fracture

 

A.  Subsidence

- 1-2 mm normal in first year

- > 5 mm abnormal

- measure from tip GT to head neck junction

 

B.  Medial midstem pivot

- pivots about midstem

- proximal medial, distal lateral

- poor cement superomedial or inferolateral

 

C.  Calcar pivot / bending cantilever

- distal fix strong, but proximally loose

- breakdown of proximal cement

- bone destruction

 

Uncemented femur

 

Engh classification

 

Types based on presence of radiolucent lines (RLL)

 

I.  Stable bony ingrowth

 

Take one year to see

A.  Spot welds at end of porous coating

B.  Absence of RLL next to porous coating

- may have RLL next to non porous coated areas

C.  Calcar atrophy secondary to stress shielding

 

THR Uncemented Proximal Stress ShieldingTHR Uncemented Stem Spot Weld APTHR Uncemented Stem Spot Weld Lateral

 

II Stable fibrous ingrowth

A.  No spot welds

B.  Parallel sclerotic lines / RLL about porous coating

C.  No migration

 

THR Uncemented Stem Stable sclerotic lines

 

III Unstable fibrous ingrowth

A.  Component migration

B.  Progressive increase RLL

- divergent RLL

C.  Pedestal formation (bony hypertrophy at tip)

 

THR Uncemented Subsidence

 

Uncemented Acetabular Component

 

Concepts

 

Bone ingrowth into component averages only 12% 

- even with 84% bone contact

 

Non continuous radiolucent lines 

- commonly found in press fit acetabular components 

- are often not progressive

 

Radiographic signs of ingrowth fixation

 

Moore et al CORR 2006

- 3 or more 97% stable

- 2 or less, 83% unstable

 

Five signs

- absence of radiolucent lines

- presence of a superolateral buttress

- medial bone stress-shielding

- radial trabeculae

- inferomedial buttress

 

THR Uncemented Cup Superolateral Buttress 2

 

Radiographic signs of loosening

 

5 signs

- radiolucent lines that appear after two years

- progression of radiolucent lines after two years

- radiolucent lines in all three zones

- radiolucent lines 2 mm or wider in any zone

- migration > 2mm

 

Loose Uncemented CupLoose Uncemented Cup 2

 

Engh Classification

 

I  Osse-ointegration

 

A  No RLL

B  One RLL zone 1 or 2

C  RLL zones 1 & 2

 

THR Uncemented Cup Stable RLL Zone 1Uncemented Cup No RLL

 

II Stable fibrous ingrowth

- <2mm zone 3

 

Uncemented Cup Stable Fibrous Ingrowth

 

III Unstable fibrous ingrowth

- >2mm RLL in zone 3

B Assessment Bone Loss

IndicationsRevision THR CT scan Bone Defects

 

1.  Loosening
2.  Infection
3.  Instability
4.  Periprosthetic fracture


Objective


1.  Exclude infection
2.  Re-establish the structural integrity & bone stock
3.  Establish normal Joint mechanics
- restore the centre of rotation of the hip
4.  Initial rigid fixation of bone graft
5.  Adequate containment of the new prosthesis

 

Aetiology Bone Loss


1.  Osteolysis
2.  Surgical / iatrogenic (with implant removal)
3.  Acetabular dysplasia
4.  Fracture
5.  Infection

 

Preoperative Assessment


1.  Exclude infection
2.  Quantify bone loss

 

Classifications

 

Femoral

- Paprosky

- AAOS

 

Acetabular

- AAOS
- Paprosky

 

Femoral Bone Loss

 

Paprosky Classification
 

I Minimal metaphyseal cancellous bone loss / intact diaphysis
- i.e. seen after removal of uncemented component without biological ingrowth on surface
 

II Extensive metaphyseal cancellous bone loss / intact diaphysis
- often seen after removal of cemented prosthesis

 

Revision THR Paprosky II FemurRevision THR Paprosky II


IIIA Metaphysis severely damaged / > 4cm diaphyseal bone for distal fixation
- grossly loose femoral component
- first generation cementing techniques

 

Revision THR Paprosky IIIA FemurRevision THR Paprosky IIIA 3


IIIB Metaphysis severely damaged / < 4cm diaphyseal bone for distal fixation
- cemented with cement restrictor
- uncemented with substantial distal osteolysis

 

Infected THR Paprosky Type IIIA


IV Extensive metaphyseal and diaphyseal bone loss / isthmus non supportive

 

AAOS Classification


I Segmental
- proximal (partial or complete)           
- intercalary
- greater trochanter


II Cavitary
- cancellous
- cortical
- ectasia (dilatation)


III Combined segmental and cavity


IV Malalignment
- rotational
- angular


V Femoral Stenosis


VI Femoral Discontinuity

 

Acetabular Bone Loss
 

AAOS Classification


Type I    Segmental deficiencies

Peripheral -  superior / anterior / posterior

Central - medial wall absent

 

Revision THR Anterior wall segmental defect


Type II    Cavitary deficiencies


Peripheral  -  superior / anterior / posterior
Central - medial wall intact

 

Revision THR Cavitatory Deficiency CupRevision THR Contained Defect Cup CTRevision THR Cemented Cup Anterior Wall Intact


Type III    Combined deficiencies


Type IV     Pelvic discontinuity

 

Separation of anterior and posterior columns


Type V    Arthrodesis

 

Paprosky Classification


Based on ability of the remaining host bone

- to provide initial stability to a hemispherical cementless acetabular component

- until ingrowth occurs


Type 1    

 

Undistorted rim
- anterior and posterior columns intact
- no superior migration

- may have some contained deformities
- ishium, teardrop and Kohlers line intact


Type 2

 

Distorted but intact rim
- can support a hemispherical cementless implant

 

Revision THR Paprosky Type 2 Cup

 

Some distortion, minimal superior migration
- at least 50% good support by host bone
- anterior and posterior columns intact
- no substantial osteolysis of ischium or teardrop

 

2A

- superomedial migration but superior rim intact

 

Revision Acetabulum Paprosky Type IIA

 

2B

- < 1/3 superior deficit

- remainder is still supportive

- replace with allograft for bone stock

 

2C

- medial migration to Kohlers, but wall intact

- rim is supportive

- manage as for protrusio

 

Revision Acetabulum Paprosky Type IICRevision THR Superior Migration Cup but Rim intact


Type 3

 

Non supportive rim
- columns not supportive, superior migration> 3 cm

- require structural allograft for support

 

Revision THR Type 3 Acetabulum


4 radiographic criteria


1.  Superior migration of the hip centre
- indicates damage to anterior and posterior columns
- supero-medial indicates greater damage to anterior column
- supero-lateral indicates greater damage to posterior column


2.  Ischial osteolysis
- bone loss inferior posterior column


3.  Teardrop osteolysis
- inferior anterior column and medial wall


4.  Position of the implant relative to Kohler’s line
- deficiency of anterior column

 

3A

-  > 40% host bone contact

-  < 50% rim missing

 

3B

- < 40% host bone contact

- > 50% rim missing

 

 

C Approach and Implant Removal

Pre-operative Planning


CT / quantify bone loss
X match 4 units
Cell saver
Anaesthetic review
Bone graft (cortical, cancellous)
Component removal gear

- extraction gear for femur / liners

- cement removers for cemented femur

- curved osteotomes for cemented cup

- X-plant for uncemented cup
Revision long stem femoral implants
Revision acetabular implants including cages

 

Exposure


Posterior approach
- often easiest in revision
- good for ETO

 

Recreate fascial and muscular layers

- aids exposure and closure

Wide exposure of hip joint
- removal of all pseudocapsule
- expose entire proximal femur & acetabulum

 

Extended Trochanteric osteotomy

 

Concept

 

Osteotomy lateral 1/3 to 1/2 of trochanter / femur

- posterior to anterior longitudinal cut

- short distal transverse cut

- levers / hinges open anteriorly

- maintains anterior vasculature / muscle attachment

 

Indications


1.  Aid exposure
2.  Removal cement (especially infection)
3.  Removal well fixed uncemented prosthesis
4.  Removal cement plug / bone very poor / risk of perforation high
5.  Abnormalities of the proximal femur


Contraindications / Relative


1.  Impaction bone grafting
2.  Cementing revision prosthesis

 

Technique ETO
 

Length
- measured from tip GT
- 2 – 15 cm long
- need to preserve diaphysis if using distal press fit uncemented stem


Timing
- usually after implant removal
- may not be possible


Site
- elevate vas lateralis forward
- expose linea aspera
- expose posterior femur


Osteotomy
- use drill holes to mark osteotomy

- drill both cortices
- thin oscillating saw
- cut down through anterior and posterior femur in line with GT
- through both cortices
- transverse cut distally through 1/3 diameter
- lever open


Fixation
- 3 x cerclage cables, tension
- protect sciatic nerve
- submuscular

 

Results
 

98 – 100% union rate by 6/12

 

Removal Femoral Implant


A.  Cemented

 

Initially

- must clear shoulder of prosthesis
- must ensure no GT overhang or will fracture on removal


Extraction devices
- stem often easily removed if cemented
- extraction devices hook around proximal prosthesis & backslap
- can release cement – implant interface
- combination flexible osteotomes, micro sagittal saw, small burr


Cement removal
- aided by ETO
- use arthroscopy light down femur


Cement removal kit
- flexible osteotomes, reverse hooks, cement splitters
- split cement radially & then removed
- can use high-speed burr
- may require distal window


Removal of cement plug
- remove proximal cement
- drill guide in centraliser
- insert tap, then extract

 

Need to be very careful to avoid inadvertant perforation


B.  Uncemented


Can be very difficult to remove a well fixed stem

- i.e. if removing for infection


Consider component design
- proximally coated
- extensively coated


Breakdown osseointegration
- flexible osteotomes
- sagittal saw
- very difficult
- can perform ETO about stem


Extraction devices

- company specific

- hook under neck

 

Broken Stems
- stem is invariably well fixed distally
- osteotomy to site of fracture
- +/- distal window


Acetabulum Removal

 

Acetabular revision only


1.  Leave femoral component in situ

 

Indications

- femur not loose / damaged / good orientation

- need to be able to match new cup / poly to femoral head

 

Technique
- can remove head if modular (use company device to lever off)
- make anterior pocket for femoral stem

- protect trunion with swab

 

Note

- can be a problem putting a ceramic head on an old trunion

- if needed, can get a ceramic head with a metal liner for trunion


2. Removal of cemented Femoral component / Re-cement a smaller prosthesis into a well fixed cement mantle

 

Revision Cup Only Cement in Cement Femur PreRevision Cup Only Cement in Cement Femur Post


Removal
- as above

 

Re-cement prosthesis

- ensure cement mantle clean and dry

- trial small component

- cement in cement revison with high viscosity cement

- insert cement when very viscous

- put in new prosthesis very early

 

Removal Cemented Acetabulum


1.  General principle is to loosen poly cup from cement
- do so with curved gouges
- between cement & cup
- cement then removed piecemeal


2.  Can simply ream out the poly


3.  Insert threaded extractor through drill hole in poly
- then disimpact poly from cement

 

Uncemented Acetabulum


Options
- may just be changing liner and leaving cup
- may need to remove well fixed cup i.e. infection

- may be removing loose cup


Liner

1.  Company specific removal instruments
- need to disengage locking mechanism


2.  Simply lever out liner with osteotomes


3. Drill hole in liner 4.5 mm
- insert 6.5 mm screw to push liner out


Metal Shell

1.  Curved osteotomes
- risk bone loss


2.  Zimmer Explant Acetabular Removal System
- 3 sizes depending on implant size
- central head to sit in liner
- must remove screws first, then replace liner
- diamond blades cut between cup and bone
- initial blade short
- second is thin and full radius
 

Intrapelvic acetabulum / cement

 

Intrapelvic Cement

 

Issue


Can be life threatening if just pulled out from standard approach
 

Workup


Preoperative contrast studies

General surgeon / vascular surgeon available

 

Options


A.  No aneurysm
- lateral window of ilioinguinal
- elevate iliacus subperiosteally from table of ilium
- remove under direct vision


B.  False aneurysm
- Rutherford Morison approach
- general / vascular surgeon

 

 

D Reimplantation Acetabulum

Principles of Acetabular reconstructionRevision Acetabulum Post Paprosky Type IIIC

 

Restore centre of rotation
Restore acetabular integrity
Component containment
Secure fixation


Preoperatively planning


Know components in situ (esp if leaving femur)
Quantify and grade bone defects
Beware intrapelvic cement / cup (angiogram)

 

Basic Guidelines

 

> 50% host bone contact

- use press fit uncemented cup augmented with screws

 

< 50% host bone contact

- use metal augment in elderly to reconstruct defect

- use allograft augment in young to reconstruct defect

- press fit cup if able

- otherwise must use cage


Paprosky Type I, II A and B

 

I Rim intact

II A Mild superior migration / superior rim intact

II B < 30% superior rim missing


1.  Uncemented Jumbo rim fit cup


Indications
- > 50% host bone available for ingrowth
- > 2/3 rim intact


Technique
- implant in usual position
- preferentially ream anteriorly
- preserve posterior column
- some uncovering superiorly allowed
- usually augment with screws
- +/- postoperatively NWB 6/52


Results
- 12-15 year survival between 81-96%

 

Revison THR Type I AcetabulumRevision THR Jumbo Cup 2

 

2.  Impaction Bone Graft +/- Mesh + Cemented Cup

 

Revision Acetabulum Type IIIBRevision Acetabulum Type IIB Superior Mesh and Impaction Bone Graft

 

Type IIC

 

Type IIC: Medial wall deficiency but intact


Options


A.  Particulate graft medially, jumbo cup

 

Revision THR Type IIC AcetabulumRevision THR IIC Jumbo Cup + medial bone graft

 

B. Impaction bone graft, cemented cup

 

Revision Acetabulum Type IICRevision Acetabulum Type IIC Impaction Bone Grafting

 

C.  Cement +++

 

Indicated in elderly patients

 

Revision Acetabulum Type IIcRevision Acetabulum Cement +++

 

Segmental Medial Wall deficiency


A.  Allograft + Antiprotrusio Cages + Cemented Cup

 

Types
- Ganz / Muller / Burch Schneider

- variations on them

- hook or screws into ilium

- hook or screws onto ischium

- can have extension for screws onto pubis

 

Revision THR Burch Schneider Cage
 

B.  Mesh + Impaction Bone grafting

 

Type IIIA defects

 

Type IIIA

- Rim < 50% missing, > 40% host bone contact

- want to reconstruct defect but don't need cage

 

1.  Uncemented rim fit cup / screws / Structural bone graft


Indications
- defect superolateral rim < 50% to support cup
- > 50% host bone contact

- allograft will not grow onto uncemented cup

- allograft to reconstuct defect


Technique
- femoral head allograft reconstruction (no 7 shape)
- fix with 6.5 mm screws
- tap first to prevent fracture
- ream into bone


2.  Impaction bone graft +/- mesh + cemented cup
 

Revision THR Type IIC AcetabulumRevision THR Impaction Bone Graft Acetabulum

 

Technique


1.  If required, convert uncontained defect into contained defect
- use titanium mesh fixed with screws
- acetabular rim or medial wall mesh (Stryker)

 

Revision THR Type IIIC Acetabulum Mesh Impaction Bone GraftRevision THR Type IIIA Acetabulum Pre IBG


2.  Impact morcellised cancellous bone graft
- tamps or reverse reaming
- progressively smaller impactors
- need 5 mm of bone graft


3.  Insert prosthesis / Cemented poly liner


Results


- 85% 12 year survival
- 80% 15 year survival


Important Points


1.  Rigorous technique important


2.  Fresh frozen allograft
- does this perform better than irradiated BG


3.  TWB 6 – 12/52

 

3.  Trabecular metal components


New material made of element tantalum

1.  Interconnecting porous material
- 80% porous
- allows 2-3 X bony ingrowth


2.  Less stiff
- improved remodelling of BG underneath


3.  High cancellous bone coefficient of friction
- excellent initial stability
- may need less than traditional 50% host bone contact
- may not need screws


Ream host bone for press fit cut
- trial then secure trabecular augment with screws
- press fit cup with cement between augment and cup
- screw augmentation of cup
 

4.  Bilobed uncemented acetabular components

 

Bilobed Revision Cup


Indications
- superolateral deficiency
- revision
- DDH cups


Problems
- can be difficult to get version right
 

Type IIIC

 

Type IIIC

- < 50% rim intact, < 40% contact

- must reconstruct for stability

- unable to use uncemented component

- use bone graft to reconstruct

- need cage for stability

 

1.  Structural Allograft + Cage

 

Revision Acetabulum Bulk Structural Allograft + Cage


Indications
- when inadequate bone stock precludes the use of uncemented acetabular components


Theory
- cannot implant onto allograft
- graft under the cage
- secure with cage
- cement poly into it


Technique
- allograft reconstruction of rim with femoral head
- allograft particulate material in base
- secure cage to posterior column ilium and ischium
- 3 screws in each
- cement all poly cup into cage


Results
- 75% 10 – 15 year survival
 

Option:  Custom-made triflange components


CT guided model of pelvis
- custom made acetabular cage
- fits defect exactly
- flanges perfectly designed and not malleable to improve strength
- HA coated
- cement poly cup into it


Indications
- massive defects


Results
- 90% 4.5 year survival in complicated patients

 

2.  Impaction Bone Graft +/- Mesh + Cage + Cemented cup

 

Revision THR Type 3B AcetabulumRevision THR Acetabular Mesh Bone Graft Cage

 

Pelvic discontinuity

 

Revision THR Pelvic Discontinuity0001Revision THR Pelvic Discontinuity 2Revision THR Pelvic Discontinuity 3


1.  Plate and bone graft posterior column

 

Revision THR Plate Posterior ColumnRevision THR Plate Posterior Column Lateral


2.  Plate + Cage reconstruction
 

 

3.  Cup Cage Reconstruction

 

Technique

- large tantalam cup inserted for reconstitution of discontinuity

- bone graft inserted

- cage, cement in cup

 

Revision THR Cup Cage0001Revision THR Cup Cage0002Revision THR Cup Cage0003

 

E Reimplantation Femur

Implant Options

 

1.  Long stem cemented revision femoral stem

 

Modern cementing techniques
- removal of neocortex


Advantage
- use in all cases
- good with elderly fragile bone
- can use Abx cement (decreases infection rate)


Indications
- Paprosky Types I – IV
- very versatile

 

Technique

- complete removal / debridement of neocortex

- modern cementing techniques


Howie JBJS Br 2007
- 219 patients, 9 year follow up
- collarless double taper
- 98% 10 year survival


Problems
- ? increased non union with ETO

 

2.  Extensively porous coated diaphyseal fitting uncemented stem


Indications
- Paprosky Types I, II, IIIA


Results
- 90- 95% 10 year survival


Problems
- fracture
- stress shielding with additional proximal bone loss
 

3.  Modular diaphyseal fitting, proximal filling uncemented stem

 

Revision THR Modular Long Stem UncementedModular Revision Implants


Design
- press fit metaphyseal segment
- slotted diaphyseal segment
- initial stability through distal fixation


Indications
- Paprosky Types I – IIIB


Smith J Athroplasty 1997
- nil revisions at 5 years
- 7% radiographically loose
 

Type 3 Revision Femur 2

 

4.  Impaction bone grafting


Concept
- morcellised bone graft is osteoconductive, not osteoinduction
- resorption and eventual replacement new bone
- 6 – 12 months
- process is incomplete
 

Van der Donk Clin Orthop 2002
- 30% complete 6/12

- 90% complete 12/12

 

Requirements
1.  Particulate cancellous autograft 7-10 mm
2.  Contained defect
3.  Ability to convert uncontained into contained (i.e. mesh)


Issues
- technically demanding
- takes time
- need axial and rotational stability
- avoid stem subsidence > 5 mm


Indications
1. Uncemented distal fixation not possible (< 4cm diaphysis)
2. When reconstruction of proximal bone stock important
- young patient in whom biological solution more desirable


Technique


Templating
- choose stem 2 cortical diameters longer than most distal lytic area


Exposure
- full exposure of proximal femur
- removal stem & cement

 

Can leave distal plug
- not infected
- > 2 cm past planned tip location


Create contained defect
- reconstitute femoral tube
- create contained defect
- wire mesh & cerclage wire
- prophylactically cerclage wire shaft if diaphysis flimsy


Distal Occlusion
- threaded intramedullary plug inserted on guide rod
- impacters tested to see max depth of insertion before abutment on canal
- morsellised allograft inserted
- impactor & slap hammer slid over guide wire
- graft impacted to predetermined depth
- continued by introducing more chips with larger impacters
- stopped when level is 10 cm from tip of GT


Proximal Impaction
- appropriate proximal impactor equivalent to selected stem used
- used to force chips against walls of canal
- then larger distal impactor used
- alternated till canal filled
- should be firm neo-canal


Trial Reduction
- trial stem inserted
- depth of insertion marked
- proximal impactor driven in another 5 mm
- creates room for cement


Prosthesis
- cemented polished collarless double tapered stem


Post-op
- NWB for ? 3/52
- then gradual inc over next 3/ 12


Results


Halliday JBJS Br 2003
- 90.5% 10 year survival

Elting Clin Orthop 1995
- 93% graft incorporation
- stem subsidence in 48%

Elridge JBJS Br 1996
- > 5 mm subsidence in 22%

 

Management Plan


Assess Metaphyseal & Diaphyseal Bone Stock

Grade Paprosky, then manage appropriately


Paprosky Type 1

 

Definition


Minimal metaphyseal cancellous bone loss
Intact diaphysis     


Options

 

Simple revision
- can use standard or any revision stems


A. Uncemented
- standard length proximal fit and fill
- need appropriate initial stability


B. Cemented standard length stem
- must remove neocortex
- need good cement interdigitation

Izquierdo JBJS Br 1994
- 90.5% 19 year survival

 

Revision Femur Type 1 Standard Cemented Stem Pre opRevision Femur Type 1 Standard Cemented Stem Post op


C. Cement onto old mantle
- clean and dry mantle critical
- thin layer of blood 85% reduction shear strength

Lieberman et al JBJS Br 1993
- 19 cases
- no loosening at 5 years in all

 

Revision Femur Paprosky 1 Revision Femur Paprosky 1 Cement in old Cement Mantle

 

Type 2

 

Definition


Extensive metaphyseal cancellous bone loss
Diaphysis intact


Options

 

A.  Extensively porous coated diaphyseal fitting implant


Paprosky 90& osteointegrated

 

Calcar Replacement Uncemented Stem


B.  Long stem cemented revision stem

 

Revision Femur Long Stem Cemented Femoral Component


C.  Modular diaphyseal fitting, metaphyseal filling uncemented prosthesis


D.  Impaction bone grafting

 

Type 3A

 

Definition


Metaphysis non supportive
> 4 cm diaphysis proximal to isthmus

 

Type 3 A FemurType 3A Femur Lateral


A.  Extensively porous coated diaphyseal fitting implant

 

Type 3 Revision Femur


Paprosky 20/22 91% osseointegrated


B.  Long stem cemented revision stem

 

Revision Femur Long stem Cemented Component


C.  Modular uncemented

 

D.  Impaction bone grafting

 

Revision Femur Type IIIA Pre Impaction Bone GraftingRevision Femur Type IIIA Post Mesh and Impaction Bone Grafting

 

Type 3B

 

Definition


Metaphysis non supportive
< 4cm diaphysis proximal to isthmus

 

Options


A.  Extensively coated diaphyseal fitting

Paprosky 4/8 failed

- i.e. need > 4cm of diaphysis for this to work


B.  Long stem cemented revision stem


C.  Modular uncemented, stem with flutes for rotational stability


D.  Impaction bone grafting

 

Revision Femur Type 3 Mesh and Impaction Bone Grafting

 

Type 4

 

Definition


Metaphysis and diaphysis extensively damaged
Isthmus non supportive

 

Options


A.  Long stem cemented revision stem


B.  Impaction bone grafting

 

Management Bone Defects

 

1.  Segmental defects


A.  Must bypass any cortical defect by two cortical diameters to reduce fracture risk

B.  Cortical Strut onlay grafts
 

2.  Extensive proximal bone loss

 

A.  Calcar replacing

 

Calcar Replacing THRCalcar Replacing Hip Replacement


Indications
- proximal segmental defect < 3cm


McLaughlin JBJS Am 1996
- 38 hips 11 years
- 80% survival
- another 10% radiologically loose
- 20% dislocation rate

 

B.  Napkin ring  / Calcar graft Allograft


Indications
- circumferential proximal defects < 3cm


Results
- poor
- 40-60% resorption

 

C.  Proximal Femoral Replacement / Tumour prosthesis


Results disappointing
- however design may be improving


Malkani JBJS Br 1995
- 33 hips 11 years
- poor function (50% severe limp or unable to walk)
- 64% 12 years survival
- 22% dislocation

 

D.  Bulk Structural Proximal Femoral Allograft


Indications
- proximal defect > 3 cm


Technique
- desired stem cemented into allograft
- press fit distally into host femur
- step cut graft host junction
- secure cerclage wire and onlay cortical strut
- proximal host bone wrapped around allograft with ABD preservation

- very important – abductor mechanism must be secured and protected


Gross 1998
- 200 patients, 5 years follow up
- 12.5% revision
- revised for infection, dislocation, graft-host non union

 

Transient Osteoporosis Hip

Definition

 

Self limiting syndrome of unknown aetiology

- hip pain associated with osteoporosis of proximal femur 

 

DDx

 

AVN

- AVN of the hip in pregnancy is rare but possible

- TOH tends to be diffuse on MRI, while AVN is localised

- extends to neck and metaphysis

- transient osteoporosis has normal bone scan

 

Incidence

 

Rare

- M: F 3:1

 

Two Groups

1. Men 40-50 years old

2. Women usually 3rd trimester of pregnancy

 

Aetiology

 

Unknown / Theories

- ischaemia

- RSD

- virus / toxin

 

Only predisposing factor is pregnancy

 

Pathology

 

Biopsy shows many features in common with AVN, but it is non-specific

- edematous fluid & marrow

- inflammation

- fat necrosis

- reactive bone formation

- widely spaced trabeculae

 

Clinical Features

 

Acute onset

- AVN tends to be insidious

 

Mechanical hip pain

- usually FROM

 

Rarely sub-capital fracture results

 

Natural History

 

Three distinct temporal phases

 

1. Initial 

- sudden onset severe pain

- disability >> signs

- lasts 1/12

 

2. Plateau

- symptoms stabilise

- osteopenia seen on xray

- lasts 2/12

 

3. Regression

- lasts 3/12

 

X-ray

 

Shows diffuse osteopenia of entire proximal femur 

- 1/12 after onset

- may have "Phantom" appearance of proximal femur 

- rarely the pelvis can be affected too

 

MRI

 

Key is that with TOH the MRI changes are diffusely affecting the proximal femur

- AVN it is localized to a portion of the head

 

Marrow oedema

- TI decreased SI 

- T2 increased SI due to oedema

 

DDx

 

Radiologically 

 

AVN

Osteoporosis 2° joint disease

Metabolic cause osteopenia

Permeative - neoplasia 

 

Management

 

Pregnancy

 

NHx

 

Self limiting condition

- rapidly improves after delivery

 

Need to prevent fracture

- protected weight bearing in pregnancy

 

NOF

 

Management

- simultaneous pinning & LSCS

 

Non pregnancy

 

Bisphosphonates

 

Varenna et al Bone 2002

- 16 cases treated with IV pamidronate

- resolution of symptoms and normalisation of MRI findings

 

 

 

Trochanteric Bursitis & Gluteus Medius

Trochanteric Bursitis

 

Mechanism

 

Repetitive friction of iliotibial tract over GT

 

Aetiology

 

Overuse in athletes

Common post THR

 

May be associated with gluteus medius tears

 

Symptoms

 

Pain over upper lateral thigh with activity

- often related to hip flexion

 

Examination

 

Localised tenderness & swelling over & posterior to GT

 

Pain with resisted abduction

 

DDx

 

Tears in gluteus medius

Stress fractures

Iliopsoas tendonitis

Intra-articular hip pathology

Spinal pathology

Tumour

 

MRI

 

May demonstrate fluid in bursa

 

Non operative Management

 

HCLA injection

- virtually all respond to HCLA but may need several

- almost never need surgery

 

Operative Management

 

Bursectomy

 

Baker et al Arthroscopy 2007

- arthroscopic resection bursa in 30 patients

- successful in all but one who went on to have a successful open bursectomy

 

Bursectomy + ITB lengthening

 

Craig et al ANZ J Surg 2007

- open proximal Z lengthening ITB in 17 patients

- one poor result

- one patient had a secondary repair gluteus minimus with excellent result

 

Distal ITB lengthening

 

Pretell Int Orthop 2009

- distal lengthening in 13 patients average age 50

- 12/13 good results

- 1 post op seroma

 

Tears Gluteus Medius and Minimus

 

Aetiology

 

Sporting injuries

Falls

LLD

 

Diagnosis

 

MRI

 

Ultrasound

 

Non operative Management

 

Rest / physio

- stretching +++

- eccentric exercises

- correction of LLD with shoe lift

 

HCLA

 

ECSW

 

PRP

 

Operative Management

 

Technique

 

Repair of tears + bursectomy

- open or arthroscopic

 

Results

 

Voos et al Am J Sports Med 2009

- arthroscopic repair tendon tears in 10 patients

- all had complete resolution of symptoms

 

Lequesne Joint Bone Spine 2008

- open repair in 8 patients

- lateral tears of gluteus medius all seen on MRI

- 3 gluteus medius tears were not seen on MRI

- good results in 7/8 patients

 

Knee

ACL

A Assessment

 

ACL Normal ArthroscopyACL Normal Arthroscopy

 

Anatomy

 

Developmental Anatomy

 

Knee joint first appears as a mesenchymal cleft at 8 weeks gestation

- ACL and PCL separate entities by week 10

- cruciates principle determinants of  shape of tibiofemoral articulation 

 

Histology

 

Collagen and elastin arranged in less parallel configuration than tendons

- allows increase in length without large increase in internal stress

 

Ligaments attach to bone directly or indirectly

 

Cruciates attach directly / 4 histological zones

- ligament

- nonmineralised fibrocartilage

- mineralised fibrocartilage

- cortical bone

 

Indirect attachments via periosteum and fascia

- i.e. tibial insertion of MCL

 

Gross Anatomy

 

Intracapsular and extra-synovial

 

Direction

 

In full extension ACL

- subtends 45o angle in sagittal plane

- 25o angle in coronal plane

 

Dimensions

- 25-40 mm long

- 7-10 mm wide

 

Bundles

 

Anteromedial and posterolateral bundles

- described regarding point of tibial insertion

 

Anteromedial

- smaller

- tight in flexion

- test with anterior draw

 

Posterolateral

- larger

- tight in extension

- test with Lachman / Pivot Shift

 

Nerve

-  posterior articular nerve / branch tibial

 

Arterial supply 

- middle geniculate   

 

Origin

- medial wall LFC

- semicircular

- semicircular proximal insertion high and posterior on medial wall of LFC

 

Insertion 

- passes anteriorly, distally and medially

- oval shaped fossa anterior and between the tibial spines

- majority of ligament passes deep to transverse meniscal ligament

- a few fascicles blend with anterior horn of lateral meniscus

- variable and minor attachment to the posterior horn of the lateral meniscus

- wider and stronger than femoral insertion

 

Function

 

1° Stabilizer

- prevents anterior translation

 

2° Stabilizer

- lateral & medial stability

- protector of menisci

 

4 important features of function

 

1. Carries load throughout entire range resisting AP and translational forces

- different fibres recruited at different times 

 

2. Carries only small loads during normal activity

- about 20% of failure capacity during normal loading

 

3. Highest loads are produced by quadriceps powered extension of knee (open chain exercises)

- but during any one exercise failure loads only reach about 5%

 

4. Much more complex behaviour than just a series of fibres

- exhibits viscoelastic properties allowing it to adapt to different loading patterns

- ACL consists of many fascicle subunits

- these are recruited as needed to accommodate strain

 

Incidence

 

1:1500 - 1:3500

 

Mechanism

 

Non contact deceleration producing valgus twisting injury

 

Deceleration / ER / Valgus

 

Associated Injury

 

Meniscal Injury

 

60% lateral meniscus

- associated with acute ACL rupture

- classically posterior horn

- many will heal

 

Lateral Meniscus Posterior Horn Tear Post ACL RuptureLateral Meniscus Posterior Horn Tear Post ACL Rupture

 

40% medial meniscus

- associated with chronic ACL rupture

 

Fractures 

- 10-20%

- assciated with characteristic bone bruise patterns  on MRI

- see femoral chondral impressions from hyper-extension injury

 

Lateral Femoral Condyle Impaction Post ACL InjuryLFC Bone Bruise

 

Chondral Injuries

 

Chondral Lesion Post ACL InjuryChondral Lesion Post ACL Injury

 

MCL 

- 10-20%

 

History

 

1.  50% describe a "Pop"

 

2.  75% haemarthrosis

- intraarticular swelling or effusion within the first 2 hours after trauma suggests hemarthrosis

- swelling that occurs overnight usually is an indication of acute traumatic synovitis / meniscal tear

 

3.  Immediate inability to weight bear

 

DDx hemarthrosis 

 

Rupture of a cruciate ligament

Osteochondral fracture

Peripheral tear in the vascular portion of a meniscus

Tear in the deep portion of the joint capsule

 

Examination

 

Laxity Grading Lachmans / Anterior Draw

 

1+: mild instability < 5mm

2+: moderate instability 5-10mm

3+: severe instability >10mm

 

Lachman's 

 

20 - 30° Flexion

- removes effects of bony contour / menisci i.e. 2° constraints

- stabilise femur with one hand, other hand behind tibia with anterior force

- sublux the tibia forward

 

85% sensitivie when awake 

100% under anaesthetic

 

Lachmans PreLachman's Post

 

Anterior Draw

 

Knee at 90° Flexion with hamstring relaxed

- foot in neutral

- sit on foot to stabilise

- hands behind tibia and pull forward

- has to > 3mm different to contralateral knee

 

Anterior drawer 1Anterior Drawer 2

 

Foot in 15° of External Rotation

- medial structures tightened in this position

- reassess anterior draw

- if have positive anterior draw in this position suggests associated posteromedial injury

- ACL + MCL / Med Capsule / OPL

 

Foot in 30° of Internal Rotation

- lateral structures tight in this position

- reassess anteior draw

- if have positive anterior draw in this position suggests associated posterorlateral injury

- ACL / LCL / PLC Complex 

 

Pivot Shift

 

Concept

- ACL torn

- lateral tibia subluxed anteriorly in extension

- reduced in flexion

 

Technique

- knee moves from extension to flexion

- valgus force applied to knee

- apply axial load

- mimicking weight bearing

 

Findings

- in extension the LTC is subluxed anteriorly

- in extension ITB is in front of flexion axis and is extender of knee

- as the knee is flexed

- ITB moves behind the flexion axis and becomes flexor of knee (20-40°)

- this reduces the LTC

 

“The relocation of the subluxed lateral tibial condyle as the extended knee is flexed”

“This occurs as the ITB line of function changes so as to become a flexor rather than an extensor of the knee”

 

Lachman 1Lachman 2

 

Need 4 things for a pivot shift

1. MCL to pivot about

2. ITB to reduce on flexion

3. Ability to glide ie no meniscal tear

4. °FFD

 

Grading

 

Jakob et al JBJS Br 1987

- 3 grades with foot in varying degrees of rotation

 

Grade 1:  Pivot shift with foot IR

Grade 2:  Pivot shift with foot neutral

Grade 3:  Pivot shift with foot ER

 

X-ray

 

Usually normal

 

Segond Fracture

- small avulsion fracture of lateral proxima tibia

- is sign of lateral capsular avulsion

- pathognomonic of ACL tear

 

ACL Segond

 

Tibial avulsion

- more common in children

- can be seen in adults

 

ACL Bony Avulsion XrayACL Bony Avulsion CTACL Bony Avulsion AdultACL Bony Avulsion Sagittal MRI

 

MRI

 

Normal ACL on MRI

 

 Intact ACL T2Intact ACL T1MRI Normal ACL

 

Characteristics

- straight structure

- parallel to intercondylar notch

- no anterior subluxation of the tibia

- normal to have some increased signal due to adipose and synovial tissue

- able to see continuity of fibres from tibial to femur

 

Not always accurate

- ACL is helicoid shape

- sagittal MRI alone inaccurate in 10 - 20%

- sensitively increase to > 95% by using coronal and axial images

 

Torn ACL on MRI

 

ACL MRI Femoral ACL AvulsionACL MRI Rupture T2

 

Findings

- high signal intensity / oedema in ACL, especially accutely

- unable to identify continuous fibres from tibial to femur

- loss of taut, straight line of fibes

- loss of attachment onto LFC on axial

 

ACL Femoral Avuslion MRI

 

May see stump of ACL

 

ACL Torn with remnant stump MRI

 

May identify ACL healed onto PCL

 

MRI ACL torn and healed on PCL

 

May see tibia subluxed anteriorly

 

ACL Partial Tear

 

ACL Partial Tear

 

Bone bruising patterns

- pathognomonic

- caused by the knee pivot shifting

- terminal sulcus of LFC

- posterolateral tibial plateau

 

MRI ACL Rupture Bony Oedema Lateral Femoral CondyleMRI ACL Rupture Bone Oedema Terminal SulcusMRI ACL Rupture Bone Oedema Posterolateral Tibia

 

Mechanical Testing

 

KT 1000 

- Instrumented Lachman's and Anterior Draw

- > 3mm c.f. other knee 98% sensitive

- > 10mm absolute on one side

 

Arthroscopy

 

ACL Partial Tear ArthroscopyArthroscopy Empty Lateral Wall

 

ACL Rupture Empty Lateral WallRuptured ACL

 

Findings

- empty lateral wall

- ACL healed onto PCL

- partial tears

- ACL healed onto different part of LFC

B Management Options

NHx

 

Natural History of ACL deficient knee is variable

- functional instability 15% - 90%

- progression to OA is variable

 

Depends on level of patient demands / activity

 

1.  Late meniscal injury in ACL deficient knee

 

15-25%

 

2.  Function

 

Daniels Am J Sports Med 1994

- 292 ACL defecients knees

- 50% of patients not reconstructed returned to sport / most at reduced level

 

Frobel et al NEJM 2010

- RCT of 120 patients

- early ACL reconstruction or functional rehab with option of delayed reconstruction

- no difference between two groups

- 1/3 of patients in ACL rehab group chose to have ACL reconstructed

 

3.  Osteoarthritis

 

Daniels Am J Sports Med 1994

- higher OA in reconstructed knee v non operative

- even if remove those knees that had meniscal surgery

 

Shelbourne

- no OA in 97% of ACL reconstructed patients at 5 – 10 year follow up if

- no meniscal damage and normal cartilage at time of surgery

 

Pinczewski 

- 20% rate of OA in HS patients at 10 years

- higher in BPTB ligament

 

Non-operative Management

 

Indications

 

Patient able or willing to modify activities

No functional instability

 

Management

 

Acute phase

 

RICE, Analgesics

Weight bear as tolerated 

 

ROM exercises started early

- aim to regain full flexion & extension early

 

Muscle-strengthening

- started once FROM achieved

- quads & hamstring

- closed chain exercise

 

Resumption of sport

 

ACL rehabilitation protocol

 

Assessment

- quads and hamstring strength 90% other side

- able to perform single leg hop > 1m

 

Non-ACL Stressing ie. Bike / Swimming best

 

Avoid ACL Stressing activities

- pivoting sports

- open chain quads

 

ACL brace

- for pivoting sports

 

Operative Management

 

Indications

 

Recurrent symptomatic instability

Desire to return pivoting sport and inability to do so

 

+/- Repairable meniscus

- meniscus more likely to heal in setting of ACL Reconstruction

 

1.  ACL +  Torn Menisci 

 

Meniscal Repair

 

1.  ACL + Meniscal repair

- 60-70% success of meniscal repair without concomitant ACL reconstruction

- 90% success if repair meniscus & ACL together

 

2.  Timing 

- acute meniscal repair does better than delayed repair

- 90% heal if <8/52

- 70-80% heal if >8/52

 

3.  Side

- more medial than lateral are repairable

 

Meniscectomy 

 

Known to predispose the knee to poorer outcome

 

Kartus et al Acta Orthop Scanda 2002

- multicentred trial of over 400 patients having ACL reconstruction

- compared normal meniscus to patients who had > 1/3 meniscus removed

- meniscectomy group had more pain / swelling / laxity

- meniscectomy group had worse knee scores and more likely to have reduced ROM

 

2.  Acute locked knee & ACL 

 

Definition

- inability to flex / extend knee

- due to flipped bucket handle meniscus

 

Pseudolocking

- ACL stump causing FFD

- arthroscopy to remove blockage

 

MRI

- Confirm locked bucket handle meniscal tear

 

Need to unlock knee

 

Options

 

1.  Arthoscopy / reduce meniscus / rehab / repair both at 6 weeks

- avoids risk of arthrofibrosis

- two surgeries required

- may be best if patient has a FFD

- however the meniscus may redisplace

 

2.  Repair meniscus / rehab /  reconstruct ACL later

- problem is reduced rate of meniscus healing

- an unstable knee may retear the meniscus

 

3.  Acute ACL reconstruction and meniscal repair

- advantage is single surgery / high rate meniscus healing

- problem is risk arthrofibrosis

 

3.  Medial Collateral & ACL

 

Epidemiology

 

Grade II MCL

- 75% chance ACL rupture

 

Non-operative

 

Rehab MCL

- perform delayed reconstruction of ACL if symptomatic instability

 

ROM knee brace to limit extension

- 2 weeks 30-60°

- 2-4 weeks 30-90°

- 4-5 weeks 15˚ - 90

- 6th week 0 – 90˚

 

Indication for surgery

- MCL torn off tibia (usually off femur) and flipped up and over the pes anserinus

- won't heal in this position

- MRI all patients with MCL tenderness over tibal insertion

 

Patient with MCL and ACL instability

- reconstruct ACL

- reassess MCL at end of case

- if mildly unstable, advance / imbricate MCL on femoral side +/- tighten medial head gastrocnemius

- if severely unstable, reconstruct with hamstring or tendoachilles allograft

 

MCL Advancement

 

4.  ACL + large medial chondral lesion

 

Consider HTO + ACL

 

ACL HTO APACL HTO Lateral

 

Surgical Options

 

1.  Primary Repair

 

High failure rate

 

Reason

1. No clot formation 2° synovial fluid

2. Tension on ligament

3. Intrinsically poor healing potential

 

2.  Extra-Articular Augmentation

 

Lateral extra-articular procedures 

- prevent anterior subluxation LFC in extension

- unpopular due to poor long term results

 

1.  Ellison Procedure

 

A.  Strip of ITB Deep to LCL 

- placing it anterior in a bone trough

B.  Plication the capsular ligament

 

2.  MacIntosh Procedure

 

ITB left attached distally

- deep to LCL

- subperiosteal tunnel in LFC

- thru intermuscular septum

- back on itself distally

 

ACL Ellison APACL Ellison LateralMacIntosh ACL Scar ITB

 

3.  ACL Reconstuction

 

Graft Incorporation

 

1.  Central necrosis 

- 6 weeks post op

- strength of the graft if 70% of original at this time

 

2.  Synovialisation

- up to 6 months post op

 

ACL Graft 6 months0001ACL Graft 6 months0002

 

3.  Revascularisation

 

4.  Ligamentisation 

- 6 to 18 months

- longitudinal orientation of collagen

- normal tendon at 2 years

 

Theory

- acts as scaffold for fibroblasts

- graft undergoes ischaemic necrosis & then becomes enveloped with vascular synovial tissue

- occurs at 4-6 weeks post-op

- neovascularisation & cellular proliferation 3/12

 

 

C Surgical Reconstruction Issues

Timing of Surgery

 

Issue

- reported higher incidence with immediate reconstruction in acute phase

- reduced by settling inflammation / effusion and obtaining FROM

- always best to delay if not professional athlete

- problematic if patient has locked bucket handle mensical tear

 

Results

 

Bottoni et al Am J Sports Med 2008

- RCT of early (average 9 days) v late reconstruction (average 85 days)

- no difference between the two groups

 

Autograft Choices

 

Middle 1/3rd BPTB

 

ACL BPTB IncisionsBPTB GraftACL BPTB

 

Potential Advantages

- stiffer / perhaps increased strength and stability in contact athlete

- potentially better fixation because of bone blocks

 

Disadvantages

- risk of patella fracture

- increased anterior knee pain when kneeling

 

ACL BPTB Patella Fracture APACL BPTP Patella Fracture LateralACL BPTB Patella ORIF APACL BPTB Patella ORiF Lateral

 

4 Strand Hamstring Graft

 

Advantage

- little functional deficit

- mild knee flexion weakness

- less PFJ pain

 

Disadvantage

- ? more post operative laxity

- some weakness of hamstrings which may be important in some athletes

 

Contra-indications

- generalised ligamentous laxity

- sprinters

- hamstring injury

 

Hamstring v BPTB

 

Results

 

Spindler et al Am J Sports Med 2004

- systematic review

- no significant difference in graft failure between the two groups

- increased kneeling pain in BPTB group

 

Blau et al BMJ 2006

- meta-analysis

- some weak evidence that BPTB provides increased stability

- some evidence of lower morbidity in HS

 

Reinhardt et al Orthop Clin North America 2010

- level 1 systemic review

- failure defined as 2+ Pivot shift or revision surgery

- HS significantly higher failure rate

- significantly higher values of anterior laxity in HS

- significantly higher incidence of extension deficits in BPTB

 

3.  Allograft

 

Options

- achilles

- BPTB

- quads tendon

- tibialis anterior / posterior

 

Advantage

- nil graft site morbidity

 

Disadvantage

- disease transmission 

- high costs ($5000 per graft)

- slower incorporation (Return at 12/12 vs 6/12)

- increased failure rate

 

Results

 

Mehta et al Orthopedics 2010

- retrospective review of allograft v autograft BPTB

- 9% v <1% failure rate

 

Sun et al Arthroscopy 2009

- RCT of allograft v autograft BPTB in 156 patients

- average follow up 5 years

- no significant difference between the two groups

 

Indications

- revision

- older, lower function patients

 

4.  Synthetic

 

Advantage

- no donor site morbidity

 

Disadvantage

- poor history with regards rupture and synovitis

 

Results

 

Gao et al Arthroscopy 2010

- 159 patients followed for average 4 years

- average side to side difference 1.5 mm

- 93% satisfied or very satisfied

- 3 ruptures, one of which developed synovitis

 

Tunnel Placement

 

1.  Intra-operative tunnels

 

Isometricity does not exist

- no point on femur that maintains fixed distance from point on tibia

- up to 3 mm elongation acceptable

- graft should tighten with increased extension

 

A. Tibial tunnel 

 

Sagittal plane

- 7 mm anterior to PCL & central

- posterior 1/2 ACL footprint

 

Coronal plane

- 2/3 way towards medial tibial spine from anterior horn of lateral meniscus

 

Tunnel angle

- usually 55o

- reduce angle to shorten tunnel if have short graft

 

B. Femoral tunnel 

 

More vertical placement of tunnel

- increased AP stability

- less rotational stability / pivot shift

 

Coronal plane

- 2 o'clock rather than 1 (right knee)

- 10 o'clock rather than 11 (left knee)

 

Sagittal plane

- want to be posterior

- identify back wall in flexion

- want 2mm of back wall behind tunnel

 

2.  X-ray assessment

 

Lateral x-ray

 

Femoral tunnel

- intersection of line posterior femoral cortex and Blumensaat's line

 

Tibial tunnel

- posterior to Blumensaat's line in full extension

- parallel to Blumensaat's line

 

ACL Reconstruction Femoral Tunnels SagittalACL Reconstruction Sagittal Tibial Tunnel

 

Pinczewski JBJS Br 2008

- 200 patients followed up over 7 years

 

1.  Posterior femoral tunnel placement

- 86% along Blumensaat's line 

 

2. Anterior tibia tunnel placement

- 48% along tibial plateau

- parallel to Blumensaat's

 

ACL Reconstruction Sagittal Tunnel Measurement

 

AP Xray

 

1.  Medial tibial tunnel placement

- 46% (towards medial)

 

2.  Lateral femoral tunnel placement

- 42% from lateral LFC

 

3.  Graft inclination

- 19o

 

ACL Reconstruction AP Tunnel MeasurementsACL Reconstruction Graft Inclination Measurement

 

11% rupture rate over 7 years

- associated with posterior tibial tunnel placement

 

Good rotational stability

- 19o inclination in coronal plane

- avoid too vertical orientation

 

3.  Incorrect tunnel positions

 

Tibial Tunnel

 

A.  Anterior tibial tunnel

- impingement / limits extension / cyclops lesion

 

B. Posterior tibial tunnel

- impinge on PCL

- extension strain in extension

 

C.  Lateral tibial tunnel

- impinges on lateral wall femoral condyle

 

Femoral Tunnel

 

A.  Anterior Femoral Tunnel

- limits flexion

- increased strain in flexion / stretches graft

- increases risk of failure

 

B.  Posterior Femoral Tunnel

- excessive strain in extension

 

C.  Vertical Graft

 

Fu etal Arthroscopy 2003

- cadaver study of graft in 10 v 11 o'clock position

- demonstrated increased rotational instability in 11 o'clock

 

Options for drilling femur

 

1.   Trans - tibial 

 

Traditional techique

- drill tibial tunnel first

- place guide up tibial tunnel onto femur

 

ACL Transtibial Tunnel

 

Advantage

- cannot damage MFC

 

Potential disadvantage

- tibial tunnel sets position of femoral tunnel

- tends to make the graft more vertical

 

Technique

- drill femur with knee at 90o

 

2.  Anteromedial portal

 

Advantage

- allows separation of femoral from tibial tunnel

- can place femoral tunnel lower on femoral wall

 

ACL Anteromedial Femoral Tunnel

 

Disadvantage

- places drills and reamers close to MFC

- must be careful not to damage cartilage

 

Technique

- must hyperflex knee

- or femoral tunnel may exit in PFJ

 

Femoral Tunnel Back wall blow-out

 

Problem

 

Cannot use RCI screw to secure femoral side

 

Avoid by

 

1. Using posterior offset femoral guide

- divide tunnel size required in half and add 2

- 6mm for 7.5 mm hamstring tunnel

- 7mm for 10 mm BPTB tunnel

 

2.  Appropriate knee flexion when drilling femoral tunnel 

- hyperflexing knee if using AM portal

- 90o of flexion if using transtibial technique

 

Options

 

1.   Endo-button 

- don't need back wall for fixation

 

2.  Redrill tunnel 

- change angle by flexing knee +++

- get in good bone stock

 

3.  Fix in over the top position

- pass graft around back of femoral condyle using curved hemostat

- may need medial parapatella approach

- lateral approach to femur

- fix to femur with screw / staple

- can pass around lateral intermuscular septum and LCL

 

Notchplasty

 

ACL Large Notch OsteophyteACL Post Notchplasty

 

Issue

- smaller notch increases risk of re-rupture / stretching by causing graft impingement

- more necessary with larger grafts i.e. BPTB

- required if presence of notch osteophytes

 

Disadvantage

- notchplasty can lateralise

- important to only debride anterior portion of notch

- do not debride lateral wall or will lateralise the femoral graft

 

Techique

- trial with guide wire / reamer / chondrotome / graft

- check for lateral wall impingement

- check for roof impingement

- notchplasty as required

 

Graft Fixation

 

Graft fixation is weakest link first 6-12 weeks

- BPTB 6-10 weeks to incorporate

- HS 12 weeks (bone grows into tendon resembling Sharpey's fibres)

 

After 12 weeks the weak link is the graft

 

Options

 

Aperture Fixation

 

Interference screw

- metal / bioabsorbable

 

Suspensory Fixation

 

Endobutton

Transfix

 

ACL Transfix Pin

 

Fauno et al Arthroscopy 2005

- compared transfix and endobutton

- demonstrated increased tunnel widening with fixation away from joint i.e endobutton

 

Screws

 

Diameter

- biomechanical studies in tibia with hamstring

- line to line screw size less strong than tunnel diameter + 1

 

Length

- probably more important than diameter in hamstring

- has been demonstrated than increasing length increases fixation

- increase number of threads available for fixation

 

Divergence

- important with bone block

- must keep divergence below 200

 

Central / eccentric placement

- no significant difference

 

Metal v bioabsorbable

 

Mascarenhas Arthroscopy 2015

- meta-analysis

- no difference in outcome

- increased knee effusion, femoral tunnel widening, and screw breakage with bioabsorbable

 

Single v Double Bundle

 

Issue

 

Recurrent instability of 10-20% with single bundle

- normal ACL double bundle

- single bundle restore AP > rotatory stability

- can alter this by reducing graft verticality in coronal place

 

Disadvantage

- technically difficult

- twice as many tunnels to get wrong

- longer surgical time

- difficult revision

- no proven advantage clinically

 

Results

 

Kondo et al Am J Sports Med 2008

- prospective cohort study of 328 patients

- single v double bundle

- double bundle patients had significantly reduced anterior and rotational laxity

- no difference in clinical outcome or knee scores

 

 

D Surgical Techniques

Achilles Allograft

IndicationsAchilles Tendon Allograft

 

Revision

Multi-ligament injury

Older patient

 

Technique

 

Graft preparation

 

Calcaneal bone plug for femoral tunnel

 

Prepare bone plug

- decide on bone graft size needed

- 12 mm wide if revision / 10 mm if primary

- 20 mm long

- 10 mm deep

 

Cut with microsagittal saw

- take central third

- trim to size

- ensure passes nicely through cylinder

- no sharp edges

- drill holes as per normal bone block, 2 x 1 ethibond sutures

 

Achilles Allograft Saw Bone Block 1Achilles Allograft Saw Bone Block 2Achilles Bone Block Saw 3

 

Tendon

- 12 mm wide in man

- 10 mm in woman

 

Keep tendon long

- no need to cut short

- can cut at end of case

- the tendon will remain outside of knee

- fixate this end with Kochers

- no sutures required

 

Achilles Tendon Allograft Final

 

Tunnels

 

Drill tunnels as per standard technique

- beath pin in femur

- drill desired depth to 5 mm more than bone graft length

- eg 25 for 20

- line to line diameter

 

Fixation

 

Pass graft

 

Femoral fixation

- fix with 9 x 25 mm screw if 12 mm tunnel / graft

- otherwise 7 x 25 mm tunnel if 10 mm tunnel / graft

 

Tension graft

 

Tibial fixation

- 9 x 35 mm screw

- augment with staple

 

 

 

 

BPTB Allograft

Graft Preparation

 

BPTB Allograft Initial

 

Defrost

- in 2 litres normal saline

- can add vancomycin powder

 

Choose which part of graft to use

- usually central third

- can take either side

- try to leave sufficient graft in case of disasters

- i.e. dropping or rupturing graft

 

BPTB Allograft Tendon Cut

 

Cut tendon with knife

- 10 mm thick in women

- 12 mm thick in men or revisions

- adjust to patient's size and needs

 

Cut soft tissue on patella / tibial tuberosity ends

- usually narrow graft so becomes 10 mm wide

- can make 12 mm wide in revision setting

 

Length of bone femoral side

- usually 20 mm on femoral side

- this is usually from the patella

- cut with saw on each side

- turn and cut so is 10 mm thick

- ensure this end fits nicely through 10 mm / 12 mm tube

- this will be the passing end

 

BPTB Allograft Saw 1BPTB Allograft Saw 2

 

Length of bone on tibial side

- depends on fixation method

- risk is donor-recipient mismatch

- best to keep this side long / take from tibial end of graft

 

Graft mismatch

- if donor tendon too long for recipient knee, all bony graft will be outside tunnel

- if too short, a lot of the bony graft will be pulled into tunnel

- so keep bone graft long

- at least 30 mm

- can always shorten the tibial graft end if needed

 

BPTB Allograft Final 1BPTB Allograft Final 2

 

Drill holes x 2 in each bony block

- pass 1 ethibonds x 2 with suture passer

- tension

 

Tunnels

 

Standard tunnels via preferred technique

- tunnel diameter line to line

- femoral tunnel 5 mm deeper than bone bloc

 

Tibial fixation

- prepare a tibial groove

- using saw

- in tibia from drill hole inferiorly

- 1 cm wide, 3 cm long

- so that can secure excess tibial bone block down into this groove

 

Graft fixation

 

Pass graft

 

Fix femoral graft

- 7 x 25 screw for 10 mm graft

- same for 12 mm graft

 

Tibial graft

- either pass screw 9 x 25 mm (10 mm tunnel)

- can fix into tunnel with staples (small or medium richards)

 

ACL BPTB Allograft LateralACL BPTB Allograft AP

 

 

 

 

 

BPTB Autograft Transtibial

Harvest graft

 

BPTB IncisionBPTB ParatenonBPTB Expose TendonBPTB Measure Central Third

 

Midline incision over patella tendon

- from lower pole of patella to tibial tuberosity

- dissect fascia off tendon carefully without injuring tendon

- identify medial and lateral margins and assess tendon width

 

BPTB Central ThirdBPTB Medial CutBPTB Medial Cut 2BPTB Lateral Cut

 

Use marking pen to mark central 1 cm of tendon at distal pole patella

- can increase this to 12 - 14 mm in large male if sufficient tendon width

- use knife to cut from 2 cm on patella down medial side

- ensure leave 5 mm tendon medially

- extend 2cm down tibial tuberosity

- remeasure and cut laterally

 

BPTB Tibial Incision 2 cm longBPTB Saw CutBPTB Elevated Bone Block

 

Bone blocks

- measure 2 x 1 cm bone block on tibial tuberosity

- cut each side at 45o with saw

- 1cm deep with each saw cut meeting as triangle

- distal transverse cut 1cm deep

- lever out with curved ostetome

- make 2 x 1.5 cm drill holes with piece in situ, mark with pen

 

BPTB Patella BoneBPTB Patella SawBPTB Patella ElevationBPTB Drill in Situ

 

Repeat on patella side, can push patella down for exposure

- use smaller lever on patella side and be more delicate

- remove graft carefully, have to dissect off the fat pad

 

BPTB Graft

 

Graft preparation

 

ACL BPTB GraftACL BPTB Graft 2

 

Clean tendon of soft tissue

- decide which end will pass into femur

- usually the smaller piece

- nibble any sharp edges off especially on leading edge

- ensure whole graft will pass through 10 mm tube

- decide which end will be tibial or femoral

- mark femoral end with blue pen

- put 2 x 1 non absorbable sutures through drill holes

- probably don't need to tension BPTB

 

Knee arthroscopy

 

Medial portal

- soft spot

- make larger as need to insert 7 mm screw through here

- clean thoroughly with shaver

 

Prepare LFC

- notchplasty often required

- graft is significantly larger than HS

 

Tunnels

 

Tibial tunnel

- tibial jig / beath pin / 10 mm reamer

- need to ensure sufficient distance anterior to PCL

- use shaver to clean tunnel, especially entrance

 

ACL Tibial GuideTibial Beath Pin

 

Transtibial femoral tunnel

- need to use 7 mm offset jig to prevent posterior wall blowout

- pass femoral beath pin at 90o

- drill femoral tunnel 10 mm wide

- 5mm deeper than bone graft length

- if bone plug 20 mm long, drill 25 mm

- if bone plug 25 mm long, drill 30 mm

- need to thoroughly clean tunnel of bone debris

- can help to pass acorn reamer twice

 

ACL Femoral Offset GuideACL Transtibial Beath Pin 1ACL Transtibial Beath Pin 2ACL Femoral Acorn Drill


Graft

 

Pass loop 1 PDS though tip of beath pin

- pull 4 sutures of lead bone plug through

- advance the beath pin out of the femur

- secure sutures

 

Pass graft

- ensure bone plug passes easily into tibial tunnel

- pull up gently on sutures and advance the bone plug into knee

- use grasper to align the bone plug with the femoral tunnel

- then pull on sutures and advance the plug into the tennel

- pull femoral bone plug deep into tunnel and tension

 

Screw Fixation

 

Femoral screw

- need to be careful ans can blowout back wall or create divergent screw

- hyperflex knee +++

- this step is very important to prevent divergent screw

- expose femoral tunnel with good vision

- pass screw guide wire anterior to bone graft so as not to blow out tunnel

- insert 7 x 25 mm screw ensuring that the screw threads engage the tunnel

 

ACl Femoral Screw Guide WireACL Femoral ScrewACL BPTB in situ

 

Trial

- check no impingement

- tension tibial side at 30o

- insert 9 x 25 mm screw

 

ACL No Impingment full extension

 

Post Op xrays

 

ACL BPTB Autograft LateralACL BPTP Autograft APACL BPTP Autograft Skyling

 

 

 

 

Hamstring Graft Anteromedial

Endobutton + Interference screw +/- staple or post

 

ACL Reconstruction Hamstring Endobutton RCI Screw APACL Hamstring Graft

 

Advantage

- endobutton simple yet strong fixation

- endobutton eliminates problem if blow out back wall

- can still use femoral RCI screw if run into problems with endobutton

 

Set up

 

GA, tourniquet, IV antibiotics

- knee roll, lateral support

- knee at 90o for optimum access to notch

- but need to be able to hyperflex for femoral tunnel

- EUA to confirm positive pivot shift

- +/- pressure pump

 

Harvest graft

 

Knee flexed 90o

- usually roll tendons under finger

- longitudinal incision

- 2cm below joint line / 2 cm medial to crest / 2 cm long

- superior aspect of incision at level of tibial tuberosity

- separate skin and subcutaneous fat

- view sartorius fascia

- roll tendons again

- use knife and make cut above and parallel to gracilis

- elevate fascial flap

- used curved hook, identify both tendons first

- isolate gracilis (say Grace before Tea)

- divide vinculae (usually one)

- use tendon harvester in straight line aiming towards ischial tuberosity

- isolate ST, divide larger vinculae (there is nearly always two), strip

 

Hamstring 1Hamstring 2Hamstring 3Hamstring 4

 

Prepare graft

 

Leave tendons attached to tibia or remove and prepare on table

- remove muscle with scissors / spoon

- loop both tendons through endobutton to create 4 strand

- can suture all 4 ends together or do each 2 separately

- no 1 ethibond / ticron / fibrewire

 

Tensioner

- 10 - 15 lb