This document discusses methods for measuring and correcting limb length discrepancy (LLD) during total hip arthroplasty (THA). It describes that postoperative LLD ranges from 1-27% and can be caused by inaccurate templating, excessive acetabular reaming, or sinking of collarless stems. Intraoperative techniques aim to place reference pins or markers in the pelvis and femur to measure LLD, but these methods have limitations due to inaccurate repositioning of the limb. Newer navigation systems using CT or fluoroscopy may improve accuracy of LLD measurement and correction during THA.
INTRAMEDULLARY NAILING: RECENT ADVANCES AND FUTURE TRENDSMohd Fareed
The document summarizes the history and recent advances in intramedullary nailing. It describes the evolution of intramedullary nailing from the 1500s to modern devices. Recent advances discussed include proximal femoral nails to treat hip fractures, elastic nail systems for pediatric fractures, and drug-eluting nails. Future trends discussed are nanotechnology coatings, composite materials to reduce stress shielding, telemetric nails to monitor fracture healing, and intramedullary bone stents.
Bone grafts and bone grafts substitutessiddharth438
This document summarizes different types of bone grafts and bone graft substitutes. It discusses autogenous bone grafts which are considered the gold standard but have limitations related to donor site morbidity. Allografts from cadaveric donors are also discussed. Bone graft substitutes described include ceramics like calcium sulfate and calcium phosphate, demineralized bone matrix, and growth factors like bone morphogenetic proteins which provide osteoinduction. The properties, advantages, and limitations of each type of graft and substitute are summarized.
Primary Total Knee Arthroplasty has evolved since the 19th century with various prosthetic designs introduced over time. Prosthetic design considerations include femoral rollback, modularity, constraint, and whether to retain or sacrifice the cruciate ligaments. Radiographs are important for preoperative planning to assess alignment and bone defects. Surgical goals include restoring mechanical alignment, joint line, balanced soft tissues, and normal patellofemoral tracking. Key steps include femoral and tibial cuts, balancing the knee in flexion and extension, and addressing any flexion contractures or deformities. Complications can include nerve palsies, vascular issues, stiffness, infections, and loosening. With careful patient selection, planning and technique, total knee
Osteotomies around the hip are surgical procedures used to correct biomechanical alignment and load transmission across the hip joint. They involve removing a portion of bone. The goals are to improve femoral head coverage, containment, motion, relieve pain, and correct leg length discrepancies. Different types of osteotomies target the proximal femur or pelvis. Proximal femoral osteotomies are classified based on anatomical location and degree of displacement. Pelvic osteotomies aim to redirect the acetabulum and include Salter, Sutherland, Steel/Tonnis, and Ganz/Bernese procedures. Key considerations for each procedure include indications, approach, osteotomy cuts made, advantages/disadv
This document discusses instability after total knee arthroplasty (TKA). It begins by outlining the goals and basic principles of TKA. It then describes the bone cuts made during TKA and emphasizes that resection of the proximal tibia influences both flexion and extension gaps. The document discusses various causes of instability after TKA including improper bone cuts, soft tissue imbalance, and component malpositioning. It provides details on managing different types of instability such as instability in extension, flexion, and mid-flexion. Prevention of instability through proper bone cuts and soft tissue balancing is emphasized.
This document discusses protrusio acetabuli, a hip joint deformity where the medial wall of the acetabulum invades into the pelvic cavity. It can be caused by primary or secondary factors like infections, tumors, inflammation, trauma or genetics. The first case was described in 1824. Diagnosis involves clinical exams and radiological imaging. Treatment depends on the patient's age and bone maturity, and may include surgical closure of growth plates in children, bone grafting in adolescents, or total hip arthroplasty in older adults. Placement of the hip prosthesis component is important to avoid loosening.
This document summarizes the evolution of intramedullary nails for long bone fracture fixation from the 16th century to modern times. It describes the early use of wooden sticks and ivory implants, the introduction of metallic rods during WWI, and the development of modern locked intramedullary nails in the mid-20th century. Key figures who advanced nail design include Kuntscher, who introduced reamed nailing in 1940, and Russell and Taylor, who developed the first closed section interlocking nail in the 1980s. The document outlines the progression from first to fourth generation nails, incorporating improvements in materials, locking mechanisms, and designs to optimize stability and healing.
This document discusses total elbow arthroplasty. It provides an overview of the different types of elbow implants, including fully constrained, semi-constrained, and unconstrained designs. Semi-constrained implants are most commonly used. Patient selection criteria and contraindications are outlined. Post-operative care involves restricting motion and weight-bearing initially. Common complications include instability, polyethylene wear, osteolysis, loosening, and infection. Revision surgery may be needed in cases of painful or failed elbow replacements.
INTRAMEDULLARY NAILING: RECENT ADVANCES AND FUTURE TRENDSMohd Fareed
The document summarizes the history and recent advances in intramedullary nailing. It describes the evolution of intramedullary nailing from the 1500s to modern devices. Recent advances discussed include proximal femoral nails to treat hip fractures, elastic nail systems for pediatric fractures, and drug-eluting nails. Future trends discussed are nanotechnology coatings, composite materials to reduce stress shielding, telemetric nails to monitor fracture healing, and intramedullary bone stents.
Bone grafts and bone grafts substitutessiddharth438
This document summarizes different types of bone grafts and bone graft substitutes. It discusses autogenous bone grafts which are considered the gold standard but have limitations related to donor site morbidity. Allografts from cadaveric donors are also discussed. Bone graft substitutes described include ceramics like calcium sulfate and calcium phosphate, demineralized bone matrix, and growth factors like bone morphogenetic proteins which provide osteoinduction. The properties, advantages, and limitations of each type of graft and substitute are summarized.
Primary Total Knee Arthroplasty has evolved since the 19th century with various prosthetic designs introduced over time. Prosthetic design considerations include femoral rollback, modularity, constraint, and whether to retain or sacrifice the cruciate ligaments. Radiographs are important for preoperative planning to assess alignment and bone defects. Surgical goals include restoring mechanical alignment, joint line, balanced soft tissues, and normal patellofemoral tracking. Key steps include femoral and tibial cuts, balancing the knee in flexion and extension, and addressing any flexion contractures or deformities. Complications can include nerve palsies, vascular issues, stiffness, infections, and loosening. With careful patient selection, planning and technique, total knee
Osteotomies around the hip are surgical procedures used to correct biomechanical alignment and load transmission across the hip joint. They involve removing a portion of bone. The goals are to improve femoral head coverage, containment, motion, relieve pain, and correct leg length discrepancies. Different types of osteotomies target the proximal femur or pelvis. Proximal femoral osteotomies are classified based on anatomical location and degree of displacement. Pelvic osteotomies aim to redirect the acetabulum and include Salter, Sutherland, Steel/Tonnis, and Ganz/Bernese procedures. Key considerations for each procedure include indications, approach, osteotomy cuts made, advantages/disadv
This document discusses instability after total knee arthroplasty (TKA). It begins by outlining the goals and basic principles of TKA. It then describes the bone cuts made during TKA and emphasizes that resection of the proximal tibia influences both flexion and extension gaps. The document discusses various causes of instability after TKA including improper bone cuts, soft tissue imbalance, and component malpositioning. It provides details on managing different types of instability such as instability in extension, flexion, and mid-flexion. Prevention of instability through proper bone cuts and soft tissue balancing is emphasized.
This document discusses protrusio acetabuli, a hip joint deformity where the medial wall of the acetabulum invades into the pelvic cavity. It can be caused by primary or secondary factors like infections, tumors, inflammation, trauma or genetics. The first case was described in 1824. Diagnosis involves clinical exams and radiological imaging. Treatment depends on the patient's age and bone maturity, and may include surgical closure of growth plates in children, bone grafting in adolescents, or total hip arthroplasty in older adults. Placement of the hip prosthesis component is important to avoid loosening.
This document summarizes the evolution of intramedullary nails for long bone fracture fixation from the 16th century to modern times. It describes the early use of wooden sticks and ivory implants, the introduction of metallic rods during WWI, and the development of modern locked intramedullary nails in the mid-20th century. Key figures who advanced nail design include Kuntscher, who introduced reamed nailing in 1940, and Russell and Taylor, who developed the first closed section interlocking nail in the 1980s. The document outlines the progression from first to fourth generation nails, incorporating improvements in materials, locking mechanisms, and designs to optimize stability and healing.
This document discusses total elbow arthroplasty. It provides an overview of the different types of elbow implants, including fully constrained, semi-constrained, and unconstrained designs. Semi-constrained implants are most commonly used. Patient selection criteria and contraindications are outlined. Post-operative care involves restricting motion and weight-bearing initially. Common complications include instability, polyethylene wear, osteolysis, loosening, and infection. Revision surgery may be needed in cases of painful or failed elbow replacements.
This document provides an overview of classical shoulder arthroplasty versus reverse shoulder arthroplasty. It discusses the history, anatomy, biomechanics, prosthesis designs, surgical approaches, complications, and outcomes of both procedures. Key points include that total shoulder arthroplasty generally provides better outcomes than hemiarthroplasty, especially long-term. Reverse shoulder arthroplasty is primarily used for nonfunctional rotator cuff tears, while classical arthroplasty requires an intact rotator cuff. Complications can occur years after surgery and include loosening, infection, and fractures.
Hip dysplasia in adults, types, radiographs and management!
Useful for Orthopaedic residents and Surgeons.
Include most of the basics from reliable sources, pardon for any mistakes. Contact at singh_prabhjeet@yahoo.com for any corrections.
This document discusses longitudinal deficiency of the femoral partial (LDFP), which is a congenital absence of part or all of the femur associated with other lower limb abnormalities. It can be unilateral or bilateral. The etiology is unknown but may involve vascular or infection issues. Clinical presentation includes a shortened lower limb, thickened thigh, foot deformities, and abnormal limb positioning. Treatment options include surgical procedures like ankle disarticulation or femoral-pelvic fusion, or non-surgical approaches like prosthetics tailored to the specific classification and severity of the LDFP. Prosthetic fittings aim to address limb length discrepancy, joint instability, muscle inadequacy, and functional needs.
This document discusses high tibial osteotomy (HTO), a procedure that corrects knee alignment to relieve pressure from arthritic areas. It was first described in 1961 and involves cutting and reshaping the tibia to transfer weight from an arthritic to a healthier area of cartilage. The document outlines indications, contraindications, techniques like closing wedge and opening wedge osteotomy, management of the fibula, fixation methods, advantages and disadvantages of different techniques, expected results, and potential complications. HTO is a well-established procedure for unicompartmental knee arthritis with typical satisfactory results in 80% of cases.
Poller screws, also known as blocking screws, are non-interlocking screws placed outside an intramedullary nail to improve fracture reduction and fixation. They provide a more rigid construct by serving as a surrogate cortex where nail-cortex contact is insufficient. Their placement helps centralize the guidewire in the medullary canal and maintains reduction through a blocking effect. While there is no consensus on their exact placement, they are generally inserted on the concave side of expected deformities to prevent malalignment during nailing.
This document discusses various foot and ankle deformities and their treatments. It covers deformities including claw toes, cavus deformity, dorsal bunions, talipes equinus, talipes equino varus, and talipes equino valgus. It describes classifications of deformities and discusses tendon transfers, osteotomies, and arthrodesis procedures to correct different types of deformities based on the underlying muscle imbalances. Key considerations for surgical timing and approach are also outlined.
CORA (center of rotation of angulation)Morshed Abir
This document discusses the concept of the center of rotation of angulation (CORA) in orthopedic surgery. The CORA is the point about which a deformed bone may be rotated to achieve correction of an angular deformity without introducing a translational deformity. Proper identification of the CORA allows selection of the optimal correction axis and type of osteotomy, such as opening, closing, or dome osteotomy, to realign the bone. Correction along the bisector line passing through the CORA ensures pure angular correction without residual translation. Identification of multiple CORAs indicates more complex multi-apical or translational deformities requiring different surgical techniques.
High tibial osteotomy (HTO) is a surgical procedure that redirects the mechanical axis of the knee joint to unload the arthritic compartment and redistribute stress. The goals are to correct angular deformity at the knee and reduce pain from conditions like osteoarthritis. While HTO provides relief in the short-term, results deteriorate over time, so it is considered an interim procedure before potential knee replacement. Candidate patients are generally young and active with isolated medial compartment disease. Surgical techniques include lateral closing wedge and medial opening wedge osteotomies, with risks including patella baja, fracture, nerve injury, and non-union. HTO can postpone knee replacement surgery by 7-10 years when performed correctly.
This document discusses various surgical approaches to the hip joint, including anterior, anterolateral, lateral, and posterior approaches. It provides details on the Smith-Peterson anterior approach, including patient positioning, incision location in the internervous plane between the sartorius and tensor fascia latae muscles, and exposure of the hip joint capsule. It also describes the Watson-Jones anterolateral approach, including positioning the greater trochanter at the edge of the table, incising the fascia lata posterior to the tensor fasciae latae, and reflecting muscles to expose the joint capsule and femoral head. Finally, it outlines the lateral approach, with incision centered over the greater trochan
This document discusses various osteotomies around the hip joint. It begins with defining osteotomy and providing a brief history of important developments. It then explains the biomechanics of the hip joint and why osteotomies are effective. Several types and classifications of osteotomies are outlined. Specific procedures like McMurray's displacement osteotomy, Pauwel's varus osteotomy, and Schanz angulation osteotomy are described in detail. Contraindications and postoperative care are also mentioned.
1) HTO and UKA are surgical options for isolated medial compartment osteoarthritis of the knee. HTO aims to redistribute mechanical forces while UKA resurfaces the damaged compartment.
2) Traditionally, HTO was recommended for younger, active patients while UKA criteria included older age and lower BMI. However, criteria have expanded given improved techniques and implant designs.
3) When performed according to indications at high-volume centers, both procedures show good-to-excellent outcomes and survivorship rates over 10 years, though UKA survivorship may be higher. Global trends show a shift toward more UKAs being performed.
Soft Tissue Balancing in Primary Total Knee ArthroplastyIhab El-Desouky
The document discusses principles of soft tissue balancing during primary total knee replacement, including defining soft tissue stabilizers of the knee, techniques for soft tissue balancing like measured resection and gap balancing, and how to manage coronal plane deformities like varus and valgus knees through staged releases of tight soft tissues and bone cuts that create symmetrical flexion and extension gaps.
This document discusses vertical talus, a rare congenital foot deformity. It begins by defining vertical talus and listing its synonyms. It then discusses the etiology, associated conditions, clinical presentation, radiographic findings, and classification systems for vertical talus. The document concludes by outlining treatment approaches for vertical talus, which typically involves serial casting in infants followed by surgical correction if needed. Surgical techniques described include open reduction with possible navicular excision or arthrodesis depending on the age and severity of the deformity.
Safe surgical dislocation for femoral head fractures.dr mohamed ashraf,dr rah...drashraf369
This study evaluates the outcomes of 18 patients who underwent surgical dislocation of the hip using Ganz's technique to treat Pipkin fractures of the femoral head. Pipkin fractures are rare fractures that occur when the femoral head fractures as a result of a posterior hip dislocation. Traditional approaches provide limited exposure, while Ganz's technique allows 360 degree visualization through an anterior dislocation of the femoral head. The study found statistically significant improvements in functional scores at 1 year follow up, with no cases of avascular necrosis, demonstrating that Ganz's technique is an effective and safe method for treating these complex fractures.
This document provides an overview of hallux valgus, including its anatomy, causes, symptoms, diagnosis, and treatment options. Key points include:
- Hallux valgus is a lateral deviation of the great toe and medial deviation of the first metatarsal. It can cause pain over the bunion.
- Risk factors include heredity, footwear, ligament laxity, and pes planus. Diagnosis involves examining range of motion, deformity, and taking x-rays to measure angles.
- Treatment progresses from footwear modifications and stretching to various surgical procedures depending on severity, including distal soft tissue procedures, osteotomies, and joint fusion or replacement in severe cases.
This document provides an overview of hip osteotomies and femoral acetabular impingement (FAI). It discusses various types of osteotomies used to treat conditions like developmental dysplasia of the hip, slipped capital femoral epiphysis, and avascular necrosis. Key points include that pelvic osteotomies are best for primary acetabular dysplasia, while femoral and combined procedures are often needed in older children. The document also outlines common radiographic findings associated with pincer and cam FAI, including pistol grip deformity, acetabular retroversion, and decreased femoral head-neck offset. Risk factors and typical patient presentations are also summarized.
This document discusses the concept and methodology of templating for total hip replacement surgery. It begins by defining templating as a radiographic planning process using templates to estimate implant positioning and identify difficult cases. It then describes the goals of templating as predicting implant size and position to restore hip biomechanics. The document outlines the steps of templating, including identifying anatomical landmarks and mechanical references on radiographs. It emphasizes the importance of restoring leg length, offset, and the center of rotation.
The Masquelet technique is a two-stage process for treating bone defects using an induced membrane. In the first stage, radical debridement is performed followed by insertion of an antibiotic-loaded cement spacer and soft tissue coverage. This induces the formation of a membrane rich in growth factors. In the second stage 6-8 weeks later, the spacer is removed and cancellous bone graft is placed within the membrane chamber, which acts as a bioreactor promoting graft healing. The technique provides an alternative to bone transport or vascularized grafts for reconstructing large defects.
This document discusses limb length discrepancy (LLD) after total hip arthroplasty (THA). It defines true/structural and apparent/functional LLD and notes LLD is a common complication that can cause patient dissatisfaction. Prevalence of LLD in the general population and after THA is reviewed. Implications of LLD like increased oxygen consumption, gait abnormalities, and arthritis are covered. Methods to measure and minimize LLD are described, including intraoperative techniques using pins or callipers as references to restore leg length. Placement of the acetabular and femoral components is key to avoiding LLD, and achieving the correct femoral osteotomy level and cup position.
Templating in total hip replacement involves using preformed templates during preoperative planning to estimate implant size and position. The goals of templating include restoring hip biomechanics, predicting implant size, and recognizing potential difficulties. A standard approach involves assessing radiographs, identifying anatomical landmarks, mechanical references, and optimizing implant position. Careful templating allows surgeons to achieve successful, reproducible results while minimizing complications.
This document provides an overview of classical shoulder arthroplasty versus reverse shoulder arthroplasty. It discusses the history, anatomy, biomechanics, prosthesis designs, surgical approaches, complications, and outcomes of both procedures. Key points include that total shoulder arthroplasty generally provides better outcomes than hemiarthroplasty, especially long-term. Reverse shoulder arthroplasty is primarily used for nonfunctional rotator cuff tears, while classical arthroplasty requires an intact rotator cuff. Complications can occur years after surgery and include loosening, infection, and fractures.
Hip dysplasia in adults, types, radiographs and management!
Useful for Orthopaedic residents and Surgeons.
Include most of the basics from reliable sources, pardon for any mistakes. Contact at singh_prabhjeet@yahoo.com for any corrections.
This document discusses longitudinal deficiency of the femoral partial (LDFP), which is a congenital absence of part or all of the femur associated with other lower limb abnormalities. It can be unilateral or bilateral. The etiology is unknown but may involve vascular or infection issues. Clinical presentation includes a shortened lower limb, thickened thigh, foot deformities, and abnormal limb positioning. Treatment options include surgical procedures like ankle disarticulation or femoral-pelvic fusion, or non-surgical approaches like prosthetics tailored to the specific classification and severity of the LDFP. Prosthetic fittings aim to address limb length discrepancy, joint instability, muscle inadequacy, and functional needs.
This document discusses high tibial osteotomy (HTO), a procedure that corrects knee alignment to relieve pressure from arthritic areas. It was first described in 1961 and involves cutting and reshaping the tibia to transfer weight from an arthritic to a healthier area of cartilage. The document outlines indications, contraindications, techniques like closing wedge and opening wedge osteotomy, management of the fibula, fixation methods, advantages and disadvantages of different techniques, expected results, and potential complications. HTO is a well-established procedure for unicompartmental knee arthritis with typical satisfactory results in 80% of cases.
Poller screws, also known as blocking screws, are non-interlocking screws placed outside an intramedullary nail to improve fracture reduction and fixation. They provide a more rigid construct by serving as a surrogate cortex where nail-cortex contact is insufficient. Their placement helps centralize the guidewire in the medullary canal and maintains reduction through a blocking effect. While there is no consensus on their exact placement, they are generally inserted on the concave side of expected deformities to prevent malalignment during nailing.
This document discusses various foot and ankle deformities and their treatments. It covers deformities including claw toes, cavus deformity, dorsal bunions, talipes equinus, talipes equino varus, and talipes equino valgus. It describes classifications of deformities and discusses tendon transfers, osteotomies, and arthrodesis procedures to correct different types of deformities based on the underlying muscle imbalances. Key considerations for surgical timing and approach are also outlined.
CORA (center of rotation of angulation)Morshed Abir
This document discusses the concept of the center of rotation of angulation (CORA) in orthopedic surgery. The CORA is the point about which a deformed bone may be rotated to achieve correction of an angular deformity without introducing a translational deformity. Proper identification of the CORA allows selection of the optimal correction axis and type of osteotomy, such as opening, closing, or dome osteotomy, to realign the bone. Correction along the bisector line passing through the CORA ensures pure angular correction without residual translation. Identification of multiple CORAs indicates more complex multi-apical or translational deformities requiring different surgical techniques.
High tibial osteotomy (HTO) is a surgical procedure that redirects the mechanical axis of the knee joint to unload the arthritic compartment and redistribute stress. The goals are to correct angular deformity at the knee and reduce pain from conditions like osteoarthritis. While HTO provides relief in the short-term, results deteriorate over time, so it is considered an interim procedure before potential knee replacement. Candidate patients are generally young and active with isolated medial compartment disease. Surgical techniques include lateral closing wedge and medial opening wedge osteotomies, with risks including patella baja, fracture, nerve injury, and non-union. HTO can postpone knee replacement surgery by 7-10 years when performed correctly.
This document discusses various surgical approaches to the hip joint, including anterior, anterolateral, lateral, and posterior approaches. It provides details on the Smith-Peterson anterior approach, including patient positioning, incision location in the internervous plane between the sartorius and tensor fascia latae muscles, and exposure of the hip joint capsule. It also describes the Watson-Jones anterolateral approach, including positioning the greater trochanter at the edge of the table, incising the fascia lata posterior to the tensor fasciae latae, and reflecting muscles to expose the joint capsule and femoral head. Finally, it outlines the lateral approach, with incision centered over the greater trochan
This document discusses various osteotomies around the hip joint. It begins with defining osteotomy and providing a brief history of important developments. It then explains the biomechanics of the hip joint and why osteotomies are effective. Several types and classifications of osteotomies are outlined. Specific procedures like McMurray's displacement osteotomy, Pauwel's varus osteotomy, and Schanz angulation osteotomy are described in detail. Contraindications and postoperative care are also mentioned.
1) HTO and UKA are surgical options for isolated medial compartment osteoarthritis of the knee. HTO aims to redistribute mechanical forces while UKA resurfaces the damaged compartment.
2) Traditionally, HTO was recommended for younger, active patients while UKA criteria included older age and lower BMI. However, criteria have expanded given improved techniques and implant designs.
3) When performed according to indications at high-volume centers, both procedures show good-to-excellent outcomes and survivorship rates over 10 years, though UKA survivorship may be higher. Global trends show a shift toward more UKAs being performed.
Soft Tissue Balancing in Primary Total Knee ArthroplastyIhab El-Desouky
The document discusses principles of soft tissue balancing during primary total knee replacement, including defining soft tissue stabilizers of the knee, techniques for soft tissue balancing like measured resection and gap balancing, and how to manage coronal plane deformities like varus and valgus knees through staged releases of tight soft tissues and bone cuts that create symmetrical flexion and extension gaps.
This document discusses vertical talus, a rare congenital foot deformity. It begins by defining vertical talus and listing its synonyms. It then discusses the etiology, associated conditions, clinical presentation, radiographic findings, and classification systems for vertical talus. The document concludes by outlining treatment approaches for vertical talus, which typically involves serial casting in infants followed by surgical correction if needed. Surgical techniques described include open reduction with possible navicular excision or arthrodesis depending on the age and severity of the deformity.
Safe surgical dislocation for femoral head fractures.dr mohamed ashraf,dr rah...drashraf369
This study evaluates the outcomes of 18 patients who underwent surgical dislocation of the hip using Ganz's technique to treat Pipkin fractures of the femoral head. Pipkin fractures are rare fractures that occur when the femoral head fractures as a result of a posterior hip dislocation. Traditional approaches provide limited exposure, while Ganz's technique allows 360 degree visualization through an anterior dislocation of the femoral head. The study found statistically significant improvements in functional scores at 1 year follow up, with no cases of avascular necrosis, demonstrating that Ganz's technique is an effective and safe method for treating these complex fractures.
This document provides an overview of hallux valgus, including its anatomy, causes, symptoms, diagnosis, and treatment options. Key points include:
- Hallux valgus is a lateral deviation of the great toe and medial deviation of the first metatarsal. It can cause pain over the bunion.
- Risk factors include heredity, footwear, ligament laxity, and pes planus. Diagnosis involves examining range of motion, deformity, and taking x-rays to measure angles.
- Treatment progresses from footwear modifications and stretching to various surgical procedures depending on severity, including distal soft tissue procedures, osteotomies, and joint fusion or replacement in severe cases.
This document provides an overview of hip osteotomies and femoral acetabular impingement (FAI). It discusses various types of osteotomies used to treat conditions like developmental dysplasia of the hip, slipped capital femoral epiphysis, and avascular necrosis. Key points include that pelvic osteotomies are best for primary acetabular dysplasia, while femoral and combined procedures are often needed in older children. The document also outlines common radiographic findings associated with pincer and cam FAI, including pistol grip deformity, acetabular retroversion, and decreased femoral head-neck offset. Risk factors and typical patient presentations are also summarized.
This document discusses the concept and methodology of templating for total hip replacement surgery. It begins by defining templating as a radiographic planning process using templates to estimate implant positioning and identify difficult cases. It then describes the goals of templating as predicting implant size and position to restore hip biomechanics. The document outlines the steps of templating, including identifying anatomical landmarks and mechanical references on radiographs. It emphasizes the importance of restoring leg length, offset, and the center of rotation.
The Masquelet technique is a two-stage process for treating bone defects using an induced membrane. In the first stage, radical debridement is performed followed by insertion of an antibiotic-loaded cement spacer and soft tissue coverage. This induces the formation of a membrane rich in growth factors. In the second stage 6-8 weeks later, the spacer is removed and cancellous bone graft is placed within the membrane chamber, which acts as a bioreactor promoting graft healing. The technique provides an alternative to bone transport or vascularized grafts for reconstructing large defects.
This document discusses limb length discrepancy (LLD) after total hip arthroplasty (THA). It defines true/structural and apparent/functional LLD and notes LLD is a common complication that can cause patient dissatisfaction. Prevalence of LLD in the general population and after THA is reviewed. Implications of LLD like increased oxygen consumption, gait abnormalities, and arthritis are covered. Methods to measure and minimize LLD are described, including intraoperative techniques using pins or callipers as references to restore leg length. Placement of the acetabular and femoral components is key to avoiding LLD, and achieving the correct femoral osteotomy level and cup position.
Templating in total hip replacement involves using preformed templates during preoperative planning to estimate implant size and position. The goals of templating include restoring hip biomechanics, predicting implant size, and recognizing potential difficulties. A standard approach involves assessing radiographs, identifying anatomical landmarks, mechanical references, and optimizing implant position. Careful templating allows surgeons to achieve successful, reproducible results while minimizing complications.
Total hip replacement (THR) is a common procedure to treat arthritis of the hip. Prof. John Charnley pioneered THR in the 1960s using low-friction arthroplasty with polyethylene and acrylic bone cement. THR aims to reduce joint reaction forces by recentering the femoral head and lengthening muscle lever arms. Surgeons select implants and fixation methods based on patient factors and bone quality. Outcomes depend on restoring normal hip biomechanics and long-term implant fixation to bone.
This document provides guidelines for contouring and treatment planning for external beam radiotherapy (EBRT) in carcinoma of the cervix. It discusses the anatomy of the pelvis, staging of cervical cancer, treatment paradigms and outcomes. It then describes in detail the guidelines for contouring the clinical target volume (CTV) including the primary tumor and lymph node regions. It also outlines the dose prescription and constraints for OARs during EBRT and brachytherapy. The guidelines aim to optimize treatment planning to improve patient outcomes while reducing toxicity.
This document summarizes the key points of a procedure for total wrist arthroplasty. It begins with indications and contraindications. It then describes the implant components and surgical steps involved in implantation. The procedure involves resection of the distal radius and proximal row of carpal bones, followed by insertion of radial and carpal prosthetic components with a polyethylene bearing surface. Postoperative rehabilitation aims to achieve pain relief and functional range of motion of the wrist. Complications can include loosening and instability of the prosthetic components.
1) Computer navigation can help improve alignment and outcomes in total knee replacement surgery. Navigation systems use cameras and trackers to provide real-time positioning information to the surgeon to help accurately place implants.
2) Navigation allows for improved leg alignment within 3 degrees of normal compared to 5-7 degrees without navigation. This leads to better implant longevity and functional outcomes.
3) Surgeons can also learn "self navigation" techniques from frequent use of computer assistance, allowing accurate implant placement without reliance on the navigation system itself. This improves efficiency while maintaining positioning accuracy.
This document discusses hip arthroscopy, including hip anatomy, operative setup, portal placement, and complications. It describes the three major ligaments surrounding the hip joint and placement of the anterolateral, anterior, posterolateral, and accessory portals under fluoroscopy guidance. Operative setup involves patient positioning, equipment like arthroscopes and distractors, and preoperative imaging. Potential complications include labral/cartilage injuries, neurovascular injuries, osseous reshaping errors, anchor-related cartilage damage, fluid extravasation, hypothermia, infection, and DVT.
MRI is commonly used to evaluate the knee joint. The document outlines the standard MRI protocol for the knee, including patient positioning, coil selection, routine sequences, and advanced applications. Parameters such as slice thickness, FOV, and pulse sequences are discussed to optimize visualization of structures like ligaments, cartilage, and menisci.
1. The document discusses various radiographic positioning techniques for imaging different body parts. It includes techniques for imaging the upper limb bones and joints like the shoulder, elbow, wrist, and long bones of the arm.
2. Positioning techniques are described for imaging the subtalar joint, cervical spine, mandible, and sinuses. Oblique views, reverse waters view, and panoramic views are discussed.
3. Equipment for dental radiography and uses of split cassettes, grid cassettes, and backer's trays are also summarized. Indications for different imaging techniques are provided.
This document discusses rotator cuff tears, including the anatomy and function of the four rotator cuff muscles (supraspinatus, infraspinatus, teres minor, subscapularis). It describes the clinical examination for rotator cuff tears including specific tests. Imaging options like x-ray, MRI, ultrasound and arthrogram are discussed. Treatment options include conservative treatment or surgery like arthroscopic debridement or repair. Surgical technique, complications, and outcomes are summarized. Rotator cuff tears can range from partial to full thickness tears and prognosis depends on factors like age, tear size, and muscle atrophy.
This document provides an overview of hip anatomy, approaches to the hip joint, and the treatment of avascular necrosis (AVN) of the hip. It discusses various surgical approaches to the hip including anterior, anterolateral, lateral, posterior, and medial. It also describes the classification systems for AVN and reviews nonsurgical and surgical treatment options such as core decompression, bone grafting, osteotomies, and hip replacement. The goal of hip preserving surgeries is to redistribute weight bearing while total hip arthroplasty is recommended for late-stage AVN.
Hip Joint anatomy, surgical approches & AVN reviewdocortho Patel
This document provides an overview of hip anatomy, approaches to the hip, and the treatment of avascular necrosis (AVN) of the hip. It describes various surgical approaches to the hip including anterior, anterolateral, lateral, posterior, and medial. It also discusses the causes of AVN and classifications including Ficat & Arlet and ARCO. Surgical management of AVN including core decompression with and without bone grafting, vascularized grafts, and osteotomies are explained.
Limb length discrepancy can be congenital or acquired. It is defined as a difference in leg length of 2.5 cm or more. A short leg causes an awkward gait, increased energy expenditure, and back pain. Treatment depends on the severity and includes shoe lifts for mild cases and epiphysiodesis, shortening, or lengthening procedures for larger discrepancies. Limb lengthening uses either external fixators like the Ilizarov or internal devices to gradually lengthen the bone through the process of distraction osteogenesis, where the bone is slowly pulled apart to stimulate new bone growth. Treatment must be tailored based on the individual's age, growth remaining, and specific condition.
1) Various imaging modalities like intraoral radiography, panoramic radiography, CT scans, and cone beam CT can be used for pre-operative planning of oral implants including evaluation of bone density and dimensions.
2) Imaging stents can be used to locate intended implant sites on radiographs. Interactive software allows simulation of implant planning.
3) Post-operative assessments using serial radiographs monitor for bone loss or other signs of failure like radiolucencies around the implant. Digital subtraction radiography can measure bone density changes.
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Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
1. LIMB LENGTH
DISCREPENCY IN HIP
ARTHROPLASTY
DR RAVINDRA CHAURASIA
DEPARTMENT OF ORTHOPAEDICS
MAX HOSPITAL VAISHALI
2. INCIDENCE OF POSTOPERATIVE LLD
• Range from 1 % to 27 %.
• Lengthening is more frequent than shortening.
• The LLD is reported to vary from 3 to 70 mm.
• The postoperative LLD was less than 5 mm in 75%,
5-7 mm in 12.5%
7-10 mm in 2% of patients
(In a study conducted at the Rothman Institute, in which the direct lateral approach in the supine position was used).
• However, when care is taken to minimize LLD, the difference is
less than 10 mm in 97% of cases.
3. TRUE LLD
• Caused by lengthening of the prosthetic head-neck
distance. can be measured
1. A line drawn from the center of the femoral head to the
ankle center on full-length AP radiographs.
2. A vertical line drawn from the interteardrop line to the
lesser trochanter .
3. By comparing the position of the medial malleoli of the
patient in the supine position.
4. PREOPERATIVE MEASUREMENT.
• In full-length AP standing radiograph
LLD is measured as the difference in
length of the line segments extending
from the top of the femoral head to the
center of the ankle on each side.
• This length is modified in patients
with flexion contracture of the hip or
knee.
5. Estimation of lower limb
length discrepancy
related to the hip.
a: Biischial line
b: Interteardrop line
c: Pelvic obliquity is a
less reliable criterion:
although the hips are at
the same level, the pelvis
is oblique.
6. FUNCTIONAL LLD
• Caused by the tightness of the soft tissues about the hip
or scoliosis of the lumbar spine, causing obliquity of the
pelvis.
• Functional LLD is typically assessed when the patient is
standing and feels a sense of imbalance.
• To measure this discrepancy, measuring blocks are
placed under the short limb until the legs feel equal.
7. ACCEPATBLE LLD
• Small leg-length discrepancies (1 cm or less) are usually
well tolerated by patients and may go unnoticed.
• Discrepancies between 1 and 2 cm have been shown to
affect functional outcome scores.
• Discrepancies greater than 2 cm may lead to greater
patient dissatisfaction, nerve palsy, and back pain.
8. CONSEQUENCES OF POSTOPERATIVE LLD
• Altered balancing/ hip instability
• Back pain
• Gait disturbance
• Generalized hip pain
• Nerve pain
• Sciatic nerve palsy
• Ipsilateral knee pain
• Aseptic prosthesis loosening
• The need for a shoe lift
• Revision surgery
9. PREOPERATIVE LLD
• The short side: loss of the articular cartilage,
superior migration of the femoral head,
Requiring the surgeon to lengthen the affected limb.
• Ranawat et al showed that preoperative LLD ranges
from a 24 mm of shortening to a 5 mm of lengthening
of affected limb (mean 4.04 mm short).
10. CAUSES OF POSTOPERATIVE LIMB SHORTENING
• Inaccurate preoperative planning based on the
radiographs at several different magnifications.
• Flexion contracture of the hip joint before the surgery
• Excessive acetabular reaming during the surgery
• Sinking of the collarless stem
11. METHODS TO OVERCOME LLD
1. Preoperative Templating.
2. Intraoperative pelvic or femoral markers for reference.
3. Computer-assisted surgery or navigation or CT.
13. TWO-DIMENSIONAL TEMPLATING
• Two-dimensional templating using radiographs remains
a standard method.
• Linear measurements and calculations from plain X-
rays are susceptible to error, due to variations in
positioning of the pelvis relative to the plane of the film
and the divergence of the X-ray beams.
• The magnification issues raised by radiograph can be
overcome by using templating software.
14. USING TRACING PAPER
• The principle consists in drawing the contralateral hip
on tracing paper.
• The traces are then used to replicate the positioning of
the selected components on the abnormal hip.
• When both hips are abnormal, the Amstutz index can
be used which guides the implant positioning
according to eliminate the risk of limping.
15. THREE-DIMENSIONAL TEMPLATING
• Is performed using software developed initially to
design custom-made stems for THA. The software
compensates for poor patient positioning during
image acquisition.
18. GOALS OF AN IDEAL REFERENCING SYSTEM
• Improve the accuracy of component position
• Minimize errors of leg length
• Eliminate instability
• Maximize range of motion (ROM)
• Minimize component impingement
• Improve hip mechanics and functionality
19. ACETABULAR COMPONENT
• Concerns involving the acetabular component include cup
position, cup version, and cup tilt (abduction angle).
• The most important radiographic landmark is the teardrop
reference point, which is a guide to the inferior acetabulum.
• This is important in restoring leg length, as well as optimizing the
hip center of rotation and minimizing impingement of the
components.
20. ACETABULAR COMPONENT
• Intraoperative landmarks include the superior, anterior,
and posterior rims of the acetabulum, the sciatic notch,
and the transverse acetabular ligament.
• The anterior and posterior rims of the acetabulum are
useful as guides to the anteroposterior positioning of
the cup, as well as providing a sense of the anteversion.
21. TRANVERSE ACETABULAR LIGAMENT
• Defines the line from the posteroinferior to the anteroinferior
acetabulum. Placing the reamer parallel to the TAL represents
the patient’s native anteversion.
• The height and depth of the component positioning have also
been described relative to the TAL, with the component
optimally sitting just underneath the TAL, as does the native
acetabulum.
22. FEMORAL COMPONENT
The femoral component concerns include stem version, stem offset,
and neck length. The landmarks used for the femoral component are
various aspects of the proximal femur.
24. INTRAOPERATIVE TECHNIQUES
• Based on the distance between 2 reference points
marked on the pelvis and femur.
• Traditionally, the greater trochanter is used as an
intraoperative landmark.
• The pelvic reference can be iliac fixation pins,
intraoperative callipers, infracotyloid pins, and fixed
suture lengths.
25. INTRAOPERATIVE FIXED BONY LANDMARKS
• These landmarks are unreliable, as they may be removed
and replaced between measurements.
• Hip position must be replicated accurately in all three
planes before and after implantation of the prosthesis,
which is challenging.
• Variations in femoral abduction/adduction of only 5◦to
10◦result in measurement errors of 8 to 17 mm.
• It is believed the supine position is more reliable.
27. • Mcgee and Scott were the first to describe a simple
intraoperative technique to correct LLD in THA.
They used a fine guide wire to bend in ‘U’ shape to
act as a device to mark referencing points.
• Though they mention it has been successfully used in
200 patients, they fail to substantiate their claim with
any radiological or clinical data.
28. • Woolson and Harris later described another technique
by using a calliper device, which is more time
consuming and difficult to adopt.
• Using this device they achieved postoperative
lengthening of <6 mm in 89 % of patients. They also
fail to correlate their results to any functional
outcome.
29. Transosseous pin method. Two Kirshner wires are inserted parallel to 1 another and
perpendicular to the floor, 1 in the greater trochanter and the other in the supra-
acetabular ridge of the ilium. The caliper is placed on the pins. Intraoperative LLD is
calculated by summing the preoperative LLD with the change in length demonstrated
by the caliper
30. PCA limb lengthening gauge (Stryker, Mahwah, NJ, USA). The
left pin goes into the acetabulum, and the right pin into the femur.
A stopper and a thread cutting are added to the pin for the
acetabulum.
The disadvantage of this device is loosening of the pins in patients with osteoporotic bones,
The inaccurate abduction/adduction repositioning of the femur with respect to the pelvis
also can cause substantial error in the measurement of the length and can offset changes.
32. • Takigami et al described another technique using a
dual pin retractor for measuring the LLD. Though this
is well validated by radiological and functional
outcome.
33. The calipers dual pin retractor (CDPR). Dual pins for retracting the gluteal muscle are
connected at the “shoulder” of the CDPR. The base of the measuring ruler arm fits over the
guide pin and is removed easily after the measurement. CDPR inserted into the pelvis, about
2 to 3 cm proximal to the acetabulum
34. • Though techniques by using large Steinmann pin
have been described in literature , they have been
criticized as unreliable as they are recommended to
be removed and replaced during the surgery in
between the measurements.
36. • Naito et al , Bose, and Shiramizu et al described techniques
using a Steinman pin and adjustable calliper to achieve
intraoperative limb length correction.
• Both these techniques describe a cumbersome and
expensive device used as an adjunct in routine THA. Also
there is a need for a larger or a separate incision to
accommodate these devices for their pelvic reference
37. • Ranawat et al used vertical Steinman pin at the
infracotyloid groove of the acetabulum.
• They alluded that the points of reference are close to
center of rotation of hip, making less variations in
measurements resulting from different limb positions.
• The main limitation of this technique making it
unreliable is the difficulty in accurate positioning of
the pin due to large osteophytes at the posterior lip of
acetabulum.
38. • A simple technique described by Cuckler by using an
umbilical tape and knots to reference the bony
landmarks like ASIS.
• It is very unreliable, it is very difficult to identify the
bony prominence under surgical drapes especially in
obese patients.
39. • Matsuda et al used a ruler intraoperatively
• The main disadvantage of this method was the
difficult evaluation of acetabular component position.
40. • Another simple technique using a skin suture below
the iliac crest has been described without any clinical
or radiological correlation.
• This technique is unlikely to be reliable as the skin is
not a fixed point and differential tension on the suture
between length assessments will lead to significant
error.
41. A simple technique is by using a Judd pin (Judd
Medical, Braintree, Essex, UK) or any stout pin into the
ileum just superior to the acetabulum. A thread/suture is
then securely tied to this pin, and a knot tied in the
suture and a reference mark made with diathermy on the
greater trochanter at the level of the knot, which is then
used as a guide to either lengthen or maintain the same
length based on preoperative templating.
42. LIMITATION OF TECHNIQUES
• Linear measurements are basically based on accurate
repositioning of the leg in abduction, flexion, and
rotation.
• Hence small errors in femur repositioning can lead to
substantial errors in assessing the leg length and
offset, as the fixed reference points used is away from
center of rotation of the hip joint.
43. INTRAOPERATIVE TEST
• Shuck test, described by Charnley and involving in-line lower
limb traction in the distal direction
• Drop kick test, with the hip held in extension and the knee
flexed to 90◦; and leg-to-leg comparison of length based on the
heels or medial malleoli
• To assess soft-tissue tension and length
• The results are influenced by surgeon experience; type of
anesthesia, the approach, the patient position.
44. Abductor shuck method. The electrocautery tip indicates the abductor
musculotendinous unit, which is tensioned by a tag suture onto the greater trochanter.
The gap (or overlap) between the tenotomized ends of the abductor is measured as the
amount of limb lengthening (or shortening).
46. The ILMOD is made of two main parts –a measuring ruler
arm ① and a femoral osteotomy guide ②
47. ①The femoral head was taken out, and then an anatomical reduction of femoral neck fracture
was achieved and fixed by K-wire temporarily; ② The ILMOD was seated on the lesser
trochanter. The guide pin was pressed on the highest point of the femoral head; ③ The saw was
guided by cutting surface of osteotomy guide to create a flat resection on the femoral neck; ④
The guide pin was pressed on the highest point of the trial component
48. COMPUTER NAVIGATION
• The navigation technique has several limitations of
not only being cumbersome and expensive but also
has a steep learning curve.
• Though the measurements are calculated precisely,
the precision largely depends upon mapping and
referencing points, which are surgeon controlled,
hence the possibility of LLD remains.
49. COMPUTER NAVIGATION SYSTEMS
Quite sophisticated intraoperative support systems
• Manzotti et al used image-free navigation and
reported that the postoperative LLD was 5.06 ± 2.99
mm and the LLD was within 12 mm in all of their
patients.
• Murphy and Ecker used CT-based navigation and
reported that postoperative LLD was ranging from –5
to 3.9 mm.
50. CONCLUSIONS
• LLD is a common and recognized complication
following THA
• To overcome LLD from the numerous methods
described
• The combined use of templating to predict the
necessary length correction and plan femoral neck
osteotomy level and the intraoperative use of a simple
pelvic reference pin with accurate positioning of the
leg during measurements will provide better result
without compromising the stability of the hip.
51. • Iagulli ND, Mallory TH, Berend KR, et al. A simple and accurate method for
determining leg length in primary total hip arthroplasty. Am J Orthop (Belle Mead
NJ). 2006; 35:455- 457.
• Knight WE. Accurate determination of leg lengths during total hip replacement.
Clin Orthop Relat Res. 1977; (123):27-28.
• Kurtz WB. In situ leg length measurement technique in hip arthroplasty. J
Arthroplasty. 2011; 27:66-73.