Arthrodesis, or fusion, of the knee joint can provide relief for patients with failed knee replacements or severe deformities. Various techniques are used depending on factors like bone loss and soft tissue integrity. Compression arthrodesis with external fixation is best for infected knees with minimal bone loss, applying compression across the joint. Intramedullary rod fixation is best for extensive bone loss as it allows immediate weight bearing but risks fat embolism or disseminating infection. The goal is to achieve bony union in proper alignment within 6 months to provide a painless, stable leg.
Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
Safe surgical dislocation for femoral head fractures.dr mohamed ashraf,dr rah...drashraf369
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Deformity: It’s the position of a limb/Joint, from which it cannot be brought back to its normal anatomical position.
Described as abnormalities of :
Length
Angulation
Rotation
Translation
Combination
Safe surgical dislocation for femoral head fractures.dr mohamed ashraf,dr rah...drashraf369
femoral head fractures are very complex fractures that need immediate and prompt surgical intervention.conventional surgical appproaches to hip may lead to short and long term complications.dr mohamed ashraf ,dr rahul thampi et al are presenting their experience with gantz safe surgical dislocation approach to surgical management of femoral head fractures
Osseous anatomy, Types of approaches(Position,landmarks,Incision,Superficial and Deep surgical dissection) , structures at risk, Extensile approaches with diagrams and eponymous .
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Important surgical approaches to acetabulum and pelvis are described.
Ilioinguinal approach, Modified Stoppa Approach, Kocher lagenbeck Approach, Ilifemoral approach and extensile approaches are well illustrated and described.
Osseous anatomy, Types of approaches(Position,landmarks,Incision,Superficial and Deep surgical dissection) , structures at risk, Extensile approaches with diagrams and eponymous .
Surgical Approaches to Acetabulum and PelvisBijay Mehta
Important surgical approaches to acetabulum and pelvis are described.
Ilioinguinal approach, Modified Stoppa Approach, Kocher lagenbeck Approach, Ilifemoral approach and extensile approaches are well illustrated and described.
Fractures and fracture dislocations of the tarsometatarsal jointMurugesh M Kurani
Here I have discussed an article from Journal of Bone and Joint Surgery. The presentation includes classification, treatment, results and complications. Lets share and learn.
A short presentation on knee cap fractures its causes, diagnosis and management. This also gives brief idea about different methods of treatment for knee cap fractures.
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Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
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NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
3. History
• Albert of Vienna in 1878 - first arthrodesis -
instability of poliomyelitis
• Hibbs in 1911 -tuberculous knee
• Key (1932) - use external fixation to obtain
fusion
• Nelson and Evarts (1971)- first described knee
arthrodesis as a treatment option for failed
knee arthroplasty
5. INDICATIONS
1.Salvage of failed total knee arthroplasty
a.Secondary to infection:
1. presence of resistant organisms
2. immune compromised patient
3. gross instability
4. inadequate skin and soft tissue coverage
5. Deficient extensor mechanism
b. Patient is unwilling: revision arthroplasty
6. INDICATIONS
2.Relative indication:
1.painful ankylosis after infection
2.loss of the extensor mechanism
3.tuberculosis
4.trauma: severe destruction in young who
desire to continue vigorus activity
5.severe deformity in paralytic conditions:
-neuropathic arthropathy: DM
- malignant or potentially malignant
7. CONTRA-INDICATIONS
• Contra -lateral knee amputation
• Advanced degenerative changes in ipsilateral
hip or ankle
• Arthrodesis of the contralateral hip or knee
8. This study demonstrates the presence pathologic advancement of
degenerative osteoarthritis in the contralateral knee following arthrodesis
in a select patient cohort. Arthrodesis of the knee creates adverse
compensatory stresses on the contralateral knee which lead to symptoms
in 58% of patients and the need for surgery in 42%.
9. Biomechanics
Conway et al.
-Increased pelvic inclination
-Increased ipsilateral coxal abduction
-Increased ipsilateral dorsi-flection of the ankle
-Increased energy required for walking (plus 25 to
30%) while amputation knee 25% extra then
arthrodesis of knee
*Conway JD et al. Arthrodesis of the knee.J Bone Joint Surg Am. 2004 Apr; 86(4):835-48
10. Arthrodesis in TB Knee
Indications:
• Advanced tubercular arthritis-
- gross limitation of movements
- marked diminution of the joint space
-destruction of the apposing joint surfaces
• Tubercular arthritis with triple deformity
-gross instability
-painful ankylosis
*SM Tuli Tuberculosis of the Skeletal System(Bones, Joints, Spine and Bursal Sheaths)4 e
Triple deformity
11. Arthrodesis in TB Knee
• Charnley (1953) -
recommended compression
arthrodesis in tuberculous
knee joint in children
• compression pins are
removed around 4 weeks
• Plaster till groin should be
used in the best possible
functional position for 8
to16 weeks till osseous
fusion is demonstrable in
the x-rays
SM Tuli Tuberculosis of the Skeletal System(Bones, Joints, Spine and Bursal Sheaths)4 e
12. Arthrodesis in TB Knee
• Patient is encouraged to
walk 3 to 4 weeks after
operation.
• Weight bearing in the
plaster cast is
commenced 5 to 6
weeks after the
operation
• walking plaster is
retained for 3 to 6
months
13. Arthrodesis in charcot arthropathy
• Indications:
1.severe instability
2. soft-tissue laxity
3. bony destruction
• surgical intervention :
destructive phase – ceased radiologically
bone reconstruction - started
Sina Babazadeh et al. arthroplasty of knee joint ,Orthopedic Reviews 2010; 2:e17
14. Arthrodesis in charcot arthropathy
• Successful arthrodesis depends on :
-carefull removal of all cartilage and debris
-removal of sclerotic bone down to bleeding
-careful fashinoning of congurent surface for bone
apposition
- Firm fixatation of bone by intra medullary nail or
other methods
- Carefull debridement of all synovial tissue and
scarred capsule
*Drennan DB et .al,Important factors in achieving arthrodesis of the Charcot knee., J Bone Joint
Surg Am. 1971 Sep; 53(6):1180-93.
15. Patients concerns after knee fusion
-attention attract in public
-difficulty riding public transportation
-difficulty sitting in theaters and stadiums
- difficulty getting up after a fall
• acceptability test: simulating the functional
restrictions imposed by arthrodesis of the knee
joint with use of cast of brace
16. Pre-Operative Considerations
1. Adress:
- systemic primary disease such as DM, CVD,
endocrinological diseases ,RA
2. tumour resection:
- chemotherapy and radiotherapy-completed
to avoid the associated bone- and wound-healing
- early rehabilitation
3. examination of the limb:
-neurological and vascular status
17. Pre-Operative Considerations
4.soft-tissue situation:
- consider interdisciplinary treatment with the aid of
plastic surgery
5.radiological examinations:
-available bone & any bone defects
-whole-leg radiographs- the leg axis
-LLD
6. considerable bone loss:
- autologous as well as allografts.
-iliac crest cancellous bone,
-pedicled vascularised fibula grafts
18. Principles in arthrodesis of knee
1.Use of compression : for rigid fixation
- external fixatation
-internal fixatation
- both
2. Load bearing when possible : which increases the stability
and area of bone contact :
3. 1. contact arthrodesis (“tibio-femoral kissing”):
-direct contact between femur and tibia – bone fusion occur
3.2. non-contact arthrodesis:
-loss of bone stock is significant- need graft
4. Preserve vascularity : soft tissue
19. General principles
Aim:
overall limb alignment with the knee:
valgus :5-7 degree
flexion:10-15 degree
external rotation :10 degree
position
-extension- minimises the loss of leg length
-slight flexion- improves comfort when
seated and improves the gait pattern
21. General principles –infected TKR cont.
• first stage consists –
surgical debridement
removal of components
insertion of an antibiotic impregnated cement spacer
followed by 6– 8 weeks of antibiotic treatment based
c/s from the tissues
serial estimation of inflammatory markers
Antibiotics are discontinued - two weeks and
inflammatory markers are rechecked
• Final step -Arthodesis
22. Klinger et al classified bone loss
1. Mild—full bony contact possible
2. Moderate—incomplete bony contact
3. Severe—minimal or no bony contact
• severe bone loss-additional bone grafting
procedures including vascularised fibular graft
or allograft techniques
23. Various techniques
1. Long nail
Modular nail
Non-modular nail
2. External fixation
Monoplanar fixators
Biplanar fixators
Circular frames
3.Hybrid systems
intramedular and external techniques
4.Compression plating
24. Decision tree for specific knee arthrodesis technique with different clinicl indications
Indications for specific knee arthrodesis technique
infection
Noninfection
Severe Soft
tissue
compromise
With or without
bony defect
Severe bony
defect with or
without
soft tissue
compromise
No severe
soft tissue
compromise &
No severe bone
defect
Severe Soft
tissue
Compromise
with or without
bony defect
Severe bony
defect with or
without soft tissue
compromise
No severe soft
tissue compromise
No severe bone
defect
External
fixatation
Consider IMN
only with
concomitant
flap coverage
(Consider
antibiotic
cement coated
IMN )
Long or
shot IMN
Consider
IMN coated
with
antibiotic
cement;
Circular
external
fixator
External
fixatation :
Long or short
IMN :
(Consider
antibiotic
coated IMN)
External
fixatation
Consider IMN
only with
concomitant flap
coverage
External
fixatation :
Long or short
IMN
Compression
plate
External fixatation :
Long or short IMN
Compression plate
Source: Kim K, Snir N, Schwarzkopf R. Modern Techniques in Knee Arthrodesis. International
Journal of Orthopaedics 2016; 3(1): 487-496
25. • End point of arthrodesis:
successful when bony trabeculae traverse from
tibia to femur in at least two radiographic
projections
proper alignment :as per pre-operative
assessment
27. COMPRESSION ARTHRODESIS WITH
EXTERNAL FIXATION
Popularized by charnley –initial compression followed by
plaster cast
Indication:
infected knee
minimal bone loss with broad cancellous surfaces with
adequate cortical bone to allow good bony apposition
and compression
28. COMPRESSION ARTHRODESIS WITH
EXTERNAL FIXATION cont.
Disadvantage :
reduced fusion rates compared with intramedullary nailing
Advantages:
- application of good, stable compression across fusion site
- placement of fixation at site remote from the infected or
neuropathic joint
29. COMPRESSION ARTHRODESIS WITH
EXTERNAL FIXATION cont.
Procedure :
-with long parapatellar incision reflect patella laterally ,
expose joint and through debridement
-cut distal femur and proximal tibia using TKR guide system
-Apply biplanner external fixator to compress two surface
Denude patellofemoral surface and fix to anterior femoral
surface
30.
31. COMPRESSION ARTHRODESIS WITH
EXTERNAL FIXATION cont.
• Post operative care :
walk immediately after surgery with assistive devices bearing
weight of leg
Pin site care
once wound healed – follow up 6 weekly
till fusion Radiological and clinical union -apply long leg
orthosis /cylinder cast and full weight bearing for 4 weeks
32. Conclusion: Knee arthrodesis using a monolateral external fixator for
failed septic TKR achieved high fusion and infection eradication rates,
despite the extended time needed. When fusion is achieved, patients
had good pain relief and satisfaction.
33. ARTHRODESIS WITH
INTRAMEDULLARY ROD FIXATION
Extensive bone loss does not allow compression
- after tumor resection
- failed total knee arthroplasty
• Advantages:
Immediate weight bearing
Easier Rehabilitation
Absence of pin track complications
High fusion rate
35. • Procedure :
periprosthetic TKA infection : 2-stage procedure is
recommended
Refreshing the distal femur and proximal tibia surfaces
IM nail is inserted in an anterograde fashion through the
piriformis fossa while the distal aspect of the nail should sit
close to the tibial plafond
Severe bony defects :
allograft and autograft bone grafts or a metal or polyethylene
spacer
36.
37. • Post operative care:
Mobilized as soon as possible post operatively with assistive
device
Follow up 6 weekly
Radiological and clinical union : ambulatory aid dis continued
38. ARTHRODESIS WITH PLATE FIXATION
indications :
difficult salvage cases with severe bone loss with segmental
vascularised allogarft
advantages :
- pin track infection and pin loosening are avoided
- earlier weight bearing possible
- easier for patient in post operative period
39. • Disadvantage:
not recommended for even to low garde infection
Procedure :
Use 12-16 hole plate
Secure the plates to femur and tibia with at least five bicortical
screw through each plate in each fragment using
compression technique
40.
41. • Post operative care :
apply cylindrical cast
Allow touch down weight bearing with crutches till 12 weeks
Full weight bearing after radiological and clinical healing
42. IM nailing appears to have a higher rate of successful union but a higher risk of
recurrent infection when compared with external fixation knee arthrodesis.
43. Management of complications following
knee arthrodesis
1. Nonunion after knee arthrodesis:-
until 6-9 mo after arthrodesis procedure
range from 17% to 80%
multiple factors :
patient comorbidities
presence of active knee infection
choice of implant
Treatment options:
-bone grafting the nonunion site plus either exchange intramedullary
nailing (EIN) or supplemental plate fixation (SPF)
44. • 2. LIMB LENGTH DISCREPANCY AFTER KNEE ARTHRODESIS
goal : 2 cm LLD
fused side being shorter : allow easier foot clearance when
walking, assist in dressing ,relives tenson hamstring tendon
and sciatic nerve
treatment:
Nonoperative :shoe lift
balance issues occur more when a lift height of 5 cm or more
is required
surgical intervention:
lengthening over a nail
exchange nailing with an internal lengthening device
45. 3. THE WELL FUSED BUT INFECTED KNEE ARTHRODESIS:
-nail must be removed
- long, antibiotic cement-coated IM nail can be placed if
a large amount of bone is debrided or if the fusion is
disrupted
46. TEMPORARY KNEE FUSION FOR TREATMENT OF
INFECTED TOTAL KNEE ARTHROPLASTY
goals:
- eradication of infection
- stabilization of the knee.
articulating antibiotic cement-coated spacer
-may not provide adequate stability
- postoperative knee dislocation
- inability to bear weight
Wood JH et al. Advanced concepts in knee arthrodesis.World J Orthop 2015
47. • temporary knee fusion is accomplished by inserting
both an antibiotic cement-coated IM knee fusion nail
and a static antibiotic cement-coated spacer
• Indications:
morbidly obese
lack an extensor mechanism,
have significant soft tissue defects
have extensive distal femoral or proximal tibial bone
loss
*Wood JH et al. Advanced concepts in knee arthrodesis.World J Orthop 2015
50. Physiotherapy after knee fusion
surgery
• Early stages (1-12 weeks):
• Modalities to control pain and swelling
• Crutch training
• Non weight bearing exercises
• Strengthening exercises for muscles in unaffected leg
(quadriceps, hamstrings, calf muscles)
• Ankle exercises in affected leg
• Functional, non weight bearing activities using crutches
(climbing stairs, sit to stand, moving certain distances
etc)
51. 3-6 months:
• Partial to full weight bearing exercises as
tolerated
• Strengthening of muscles in hip, knee and ankle
in affected and non affected leg
• Stretching of quadriceps, hamstrings, hip flexor,
and calf muscles in both legs
• Range of movement exercises in hip and ankle of
affected leg
• Range of movement exercises in unaffected leg
and back
• Gait re-education
• Proprioception ( balance) training
52. 6 months onwards:
• Continuation of strengthening exercises for
both lower limbs, upper limbs, core muscles
and back
• Continuation of range of movement exercises
for both lower limbs, upper limbs, core
muscles and back
• Gait re-education
• Proprioception (balance) training
54. Summary
Major indication of arthdrodesis-salvage of infected TKR while other
are tb,neuropathic joint , malignant or potentially malignant
Patients concerns after knee fusion should be preoperatively
counselled
Pre-operative considerations are most for successful arthrodesis eg co-
morbidities ,soft tissue coverage ,bone loss status , malignant
condition , garft asessment
Position of limb in valgus :5-7 degree, flexion:10-15 degree,external
rotation :10 degree and LLD should be adressed
For infected TKR two stage procedure recommended
IMN has better union but have higher chances of infection
Illozarov’s has advantage of mechanical bone induction along with
stabilaization and correction of LLD
Post operative physiotherapy ranges from Strengthening Exercises to
weight bearing and gait re education should be well educated
55. Refrences
• Cambell operative orthopedics 13 e
• Chapmans orthopaedic surgery 3e
• Tuberculosis of skeletal system 4
• Internet