This document discusses various techniques for lumbar interbody fusion. It begins by providing background on spinal fusion and its goals of eliminating segmental motion and symptoms through bone bridging. It then reviews the history and indications for fusion, including degenerative conditions. The document focuses on the techniques of interbody fusion, including anterior approaches like anterior lumbar interbody fusion (ALIF) and lateral approaches. It discusses the advantages of ALIF like restoring lordosis and large graft surface area. It also covers posterior lumbar interbody fusion (PLIF) and complications of different approaches.
1) Lumbar interbody fusion involves placing a bone graft or interbody device between vertebral bodies to eliminate motion and promote fusion. It can be performed through anterior, posterior, or lateral approaches.
2) The anterior lumbar interbody fusion (ALIF) approach involves an abdominal incision and carries risks of abdominal organ or vascular injury but allows for larger graft placement and indirect decompression.
3) Lateral approaches like transpsoas lumbar interbody fusion (DLIF/XLIF) and oblique lumbar interbody fusion (OLIF) avoid back muscles but some levels are inaccessible and it carries risks of nerve injury.
Minimally invasive anterior spinal interbody fusion, known as oblique lumbar interbody fusion (OLIF), provides advantages over traditional anterior lumbar interbody fusion (ALIF) approaches. OLIF spares muscle and nerve trauma, avoids vascular structures, and allows single-position access to multiple lumbar levels. The authors' experience with 10 OLIF cases found good fusion rates, significant postoperative pain relief, and no procedure-related complications. OLIF restores disc height and biomechanics while achieving strong fusion through the anterior column.
1) Spinal fusion remains the gold standard for maintaining stability of unstable spinal segments caused by various pathologies like degenerative listhesis.
2) For degenerative listhesis, surgical options include decompression alone, decompression with non-instrumented fusion, and decompression with instrumented fusion, though there is no consensus.
3) Minimally invasive techniques for transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) provide similar efficacy to open techniques but with less blood loss, shorter hospital stays, and fewer complications.
1) Pelvic fractures are potentially life-threatening injuries that are increasing in incidence due to high-velocity trauma. Mortality rates are 10-15% and increase to 50% if the patient is hypotensive on initial presentation.
2) Surgical stabilization is usually indicated for rotationally or vertically unstable fractures (Tile B/C injuries). Non-operative treatment may be appropriate for stable fractures (Tile A) if displacement is minimal.
3) Anterior pelvic ring injuries involving >2.5cm of symphysis displacement are typically treated with open reduction and internal fixation. Posterior injuries are stabilized through approaches to the sacroiliac joint or ilium, using techniques like iliosacral
Simplified continuing ed talk created for hospital physical medicine and rehabilitation department in Saudi Arabia around 2013. Had/has many animations and movement in slides, which don't seem to work in slideshare? Somewhat outdated anyway, so needs updating.
**apologies for non-working animations. Haven’t had time to recreate this and try to re-upload to make them work properly. Slideshare just doesn’t display my ppt’s as created.
This document discusses pelvi-acetabular fractures. It begins with an overview noting that these fractures are potentially life-threatening and often associated with other injuries. Mortality rates are provided for different types of injuries. The anatomy of the pelvis and acetabulum is then reviewed. Historical perspectives on treatment are presented along with current principles of evaluation and management, both non-operative and operative. Classification systems for pelvic and acetabular fractures are outlined. Specific fracture patterns and approaches to treatment are covered in detail. Complications are also reviewed.
1) Pelvic fractures are associated with significant morbidity and mortality, with the ischiopubic bones, sacroiliac joint, and sacrum being most commonly injured.
2) Pelvic fractures are classified using the Tile or Young-Burgess classifications, with type I injuries usually managed non-operatively and type II and III injuries generally requiring surgical stabilization due to instability.
3) The timing of surgical fixation is dependent on hemodynamic status and associated injuries, with early fixation (<24 hours) associated with lower morbidity but also higher risk of bleeding in unstable patients. External fixation can be used initially in hemodynamically unstable patients before definitive fixation.
1) Lumbar interbody fusion involves placing a bone graft or interbody device between vertebral bodies to eliminate motion and promote fusion. It can be performed through anterior, posterior, or lateral approaches.
2) The anterior lumbar interbody fusion (ALIF) approach involves an abdominal incision and carries risks of abdominal organ or vascular injury but allows for larger graft placement and indirect decompression.
3) Lateral approaches like transpsoas lumbar interbody fusion (DLIF/XLIF) and oblique lumbar interbody fusion (OLIF) avoid back muscles but some levels are inaccessible and it carries risks of nerve injury.
Minimally invasive anterior spinal interbody fusion, known as oblique lumbar interbody fusion (OLIF), provides advantages over traditional anterior lumbar interbody fusion (ALIF) approaches. OLIF spares muscle and nerve trauma, avoids vascular structures, and allows single-position access to multiple lumbar levels. The authors' experience with 10 OLIF cases found good fusion rates, significant postoperative pain relief, and no procedure-related complications. OLIF restores disc height and biomechanics while achieving strong fusion through the anterior column.
1) Spinal fusion remains the gold standard for maintaining stability of unstable spinal segments caused by various pathologies like degenerative listhesis.
2) For degenerative listhesis, surgical options include decompression alone, decompression with non-instrumented fusion, and decompression with instrumented fusion, though there is no consensus.
3) Minimally invasive techniques for transforaminal lumbar interbody fusion (TLIF) and posterior lumbar interbody fusion (PLIF) provide similar efficacy to open techniques but with less blood loss, shorter hospital stays, and fewer complications.
1) Pelvic fractures are potentially life-threatening injuries that are increasing in incidence due to high-velocity trauma. Mortality rates are 10-15% and increase to 50% if the patient is hypotensive on initial presentation.
2) Surgical stabilization is usually indicated for rotationally or vertically unstable fractures (Tile B/C injuries). Non-operative treatment may be appropriate for stable fractures (Tile A) if displacement is minimal.
3) Anterior pelvic ring injuries involving >2.5cm of symphysis displacement are typically treated with open reduction and internal fixation. Posterior injuries are stabilized through approaches to the sacroiliac joint or ilium, using techniques like iliosacral
Simplified continuing ed talk created for hospital physical medicine and rehabilitation department in Saudi Arabia around 2013. Had/has many animations and movement in slides, which don't seem to work in slideshare? Somewhat outdated anyway, so needs updating.
**apologies for non-working animations. Haven’t had time to recreate this and try to re-upload to make them work properly. Slideshare just doesn’t display my ppt’s as created.
This document discusses pelvi-acetabular fractures. It begins with an overview noting that these fractures are potentially life-threatening and often associated with other injuries. Mortality rates are provided for different types of injuries. The anatomy of the pelvis and acetabulum is then reviewed. Historical perspectives on treatment are presented along with current principles of evaluation and management, both non-operative and operative. Classification systems for pelvic and acetabular fractures are outlined. Specific fracture patterns and approaches to treatment are covered in detail. Complications are also reviewed.
1) Pelvic fractures are associated with significant morbidity and mortality, with the ischiopubic bones, sacroiliac joint, and sacrum being most commonly injured.
2) Pelvic fractures are classified using the Tile or Young-Burgess classifications, with type I injuries usually managed non-operatively and type II and III injuries generally requiring surgical stabilization due to instability.
3) The timing of surgical fixation is dependent on hemodynamic status and associated injuries, with early fixation (<24 hours) associated with lower morbidity but also higher risk of bleeding in unstable patients. External fixation can be used initially in hemodynamically unstable patients before definitive fixation.
Spondylolisthesis is the forward displacement of one vertebra over another. It is graded from 0-4 based on the Meyerding grading system. Surgical options for spondylolisthesis include decompression without fusion, non-instrumented fusion, instrumented fusion using pedicle screws, and interbody fusions like anterior lumbar interbody fusion (ALIF) or lateral lumbar interbody fusion (LLIF). ALIF provides the advantage of a greater discectomy and sparing of posterior elements but has risks of visceral, ureteral, and vascular injury. LLIF avoids risks to retroperitoneal structures but may require supplemental posterolateral fusion.
This document discusses ACL injuries, including anatomy, biomechanics, mechanisms of injury, classification, clinical examination, diagnostic imaging, risk factors, and treatment options. The ACL attaches the femur to the tibia and prevents anterior tibial translation. Common mechanisms of injury include abduction, flexion, and internal rotation of the femur. Clinical examination involves assessing ligament laxity using stress tests like Lachman and pivot shift. Treatment may involve non-operative rehabilitation, repair if an avulsion fracture is present, or reconstruction using autografts like patellar or hamstring tendons. Proper graft placement and fixation are important for reconstruction to restore knee stability.
This document provides an overview of fractures of the calcaneus bone. It begins with background, noting that calcaneus fractures make up about 2% of fractures and most commonly occur in males aged 21-45 from falls or car accidents. While treatment results have historically been poor, operative fixation can provide better long-term outcomes than conservative care for displaced intra-articular fractures. The document then covers anatomy, classifications, mechanisms of injury, imaging, treatment approaches including closed reduction, open reduction and internal fixation, complications, and take-home points.
The document discusses posterior spine fixation using pedicle screw instrumentation. It provides details on the anatomy of the posterior spine elements and pedicles. Pedicle screw fixation provides a rigid construct that can increase fusion rates and reduce pain. Precise screw placement is important to avoid neurological or vascular injury. Proper preoperative planning and technique are essential to achieve a stable construct and reduce complications.
Pelvic fractures are serious injuries that require prompt evaluation and management. The presentation summarizes the seminar on pelvic fractures, covering relevant anatomy, classification systems, mechanisms of injury, clinical and radiological evaluation, emergency management, and treatment options. Definitive treatment depends on the fracture pattern and stability, ranging from closed reduction and bracing to open reduction with internal or external fixation to address anterior or posterior ring injuries. Complications can include hemorrhage, thrombosis, infection, malunion, and neurological issues.
This document provides an overview of knee anatomy and surgical procedures related to the meniscus, ACL, MCL, PCL, and patellofemoral joint. It begins with meniscal anatomy and function, then discusses factors in meniscal repair versus resection and different repair techniques. Next, it covers ACL anatomy and evidence on surgical treatment. It also discusses anatomy and treatments for MCL, PCL, and posterolateral corner injuries. Finally, it summarizes patellar instability including causes, assessment, and imaging. Key surgical procedures are highlighted throughout like ACL reconstruction techniques and options for cartilage repair.
techniques, methods, indications and complications of various fusion techniques for subaxial cervical spine. comparison of anterior versus posterior techniques, their indications and complication.
Pelvic Ring Fractures document discusses:
1) Pelvic ring fractures present challenges in immediate post-injury stabilization and later definitive management. 2) Fracture stabilization is important for unstable fractures and should be considered part of resuscitation. 3) The pelvic ring is formed by the two innominate bones and sacrum held together by ligaments, and fractures can disrupt this stability.
1. Reconstructive surgeries aim to restore skeletal continuity and function after tumor resection through techniques like arthrodesis, bone grafts, and endoprosthetic replacements.
2. Limb salvage surgery is now possible in 90% of cases due to improved chemotherapy, diagnostics, and surgical techniques. The goal is a painless, functional tumor-free limb.
3. Evaluation includes biopsy, imaging to determine tumor extent and involvement of surrounding structures, staging, and psychosocial/functional assessment. Wide local excision with clear margins while preserving neurovascular structures is key.
1. The cavus foot work-up involves identifying the underlying etiology, whether the deformity is forefoot or rearfoot driven, the plane of the deformity, and if it is rigid or flexible.
2. Common causes of cavus foot include neuromuscular conditions like cerebral palsy and Charcot-Marie-Tooth disease.
3. Treatment depends on the classification - soft tissue procedures for flexible deformities and osteotomies or arthrodesis for rigid ones. Identifying the specific nature of the deformity guides appropriate treatment.
This document provides an overview of anterior cruciate ligament (ACL) injuries, including the functions of the ACL, typical mechanisms of injury, symptoms, signs, diagnostic imaging, natural history if untreated, and treatment options. It discusses the goals of ACL reconstruction surgery, including proper graft selection, placement, tensioning, and fixation. Post-operative rehabilitation is also summarized, with the goal of regaining motion and strength while protecting the graft.
Traumatic knee dislocations are rare injuries that require careful evaluation and management. According to the document, knee dislocations often result from high-energy injuries like motor vehicle collisions or falls. A thorough examination is needed to assess vascular and neurological status. Imaging can identify associated fractures. While some stable injuries may be treated non-operatively, unstable injuries or those with ligament disruption typically require surgical reconstruction. Complications may include neurovascular injuries, infections, and long-term issues like osteoarthritis. Early surgical intervention within 3 weeks of injury may lead to better outcomes compared to delayed treatment.
Trans-facet and trans-laminar screw fixation techniques are described for posterior spinal fixation. Trans-facet screws are directed downward and laterally through the ipsilateral lamina across the facet joint, while trans-laminar screws are inserted bilaterally through the contralateral lamina and facet joints. Trans-laminar screws provide short segment fixation with less hardware and a shorter surgery time compared to pedicle screws, while still achieving adequate stability, especially when used to augment anterior fixation. Indications for these techniques include low grade spondylolisthesis and recurrent disc herniation requiring fusion.
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.
Updated PCL, PLC and Knee Dislocation for Postgraduate Orthopaedic Course in ...Professor Deiary Kader
The document discusses the posterior cruciate ligament (PCL) and posterolateral corner (PLC) of the knee. It provides details on the anatomy, mechanisms of injury, clinical assessment, treatment, and complications for injuries to these structures. For PCL injuries, the strongest ligament in the knee, treatment involves conservative management for isolated acute injuries or reconstruction for chronic symptomatic injuries. For PLC injuries, addressing all injured ligaments is important as isolated treatment can fail. Reconstruction of the lateral collateral ligament, popliteus tendon, and popliteofibular ligament is recommended for chronic complete injuries.
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.
Amputation,Stump care, phantom limb pain and gait training in lower limbHarshita89
1) Phantom limb pain and sensations are perceptions ranging from slight tingling to sharp pain that amputees feel in a limb that is no longer physically attached. It is estimated to affect 49-83% of amputees.
2) There are two main types of pain after amputation - incisional stump pain localized around the scar, and phantom pain felt in the amputated limb itself. Phantom pain can be crushing or tearing.
3) While phantom sensations often occur right after amputation, phantom pain may affect 8-10% of amputees initially but can persist for years in some cases. Stump pain is usually described as pressing, throbbing or burning.
Beverland D. Surgical Factors Influencing RomStruijs
The document discusses several factors that can influence range of motion (ROM) after knee arthroplasty surgery:
1) Surgical technique factors like thoroughly removing osteophytes, restoring proper joint alignment and posterior condylar offset, avoiding excess release of the medial collateral ligament, and closing the surgical wound in extension rather than flexion.
2) Rehabilitation protocols, including early use of continuous passive motion and adherence to post-operative physical therapy.
3) Patient factors such as pre-operative ROM, obesity, and underlying diagnosis of rheumatoid arthritis or osteoarthritis.
4) Potential treatments for stiff knees after surgery include manipulation under anesthesia and revision procedures to address issues like internal rotation of the femoral component
Pelvic fractures account for less than 5% of skeletal injuries but can be life-threatening due to potential for severe blood loss. Imaging like pelvis x-rays and CT scans are used to classify fractures by their mechanism and stability. Treatment depends on the fracture classification but may include pelvic binders, angiography with embolization for bleeding, packing or external and internal fixation for unstable fractures. Early mobilization is preferred over prolonged bed rest to prevent complications.
Pelvic injuries can be life-threatening and require a multidisciplinary approach. Classification systems help determine treatment based on fracture pattern and stability. Hemorrhage control is critical through methods like sheeting, binders, or external fixation. Surgical stabilization may be needed for instability, displacement over 5mm, or open fractures. Non-operative care is appropriate for stable, minimally displaced fractures without posterior injury. Definitive treatment involves open reduction and internal fixation, while external fixation can provide temporary stabilization. Careful preoperative planning considers patient factors and associated injuries.
Osteoporosis is a progressive bone disease characterized by low bone mass and deterioration of bone tissue, leading to increased bone fragility and risk of fractures. It occurs when bone resorption by osteoclasts exceeds bone formation by osteoblasts. Risk factors include age, gender, genetics, smoking, alcohol, obesity, low vitamin D, and medications like corticosteroids. It is diagnosed using DEXA scans and managed through lifestyle changes, calcium/vitamin D supplementation, and pharmacological therapies like bisphosphonates, strontium, raloxifene, teriparatide, calcitonin, and denosumab. Emerging therapies target mechanisms like cathepsin K, sclerost
This document discusses principles and techniques of internal fracture fixation. It defines common fracture terms like union, delayed union, and nonunion. It describes high versus low energy fractures and different fracture patterns. Key principles of fixation discussed include stability, compression, and healing mechanisms like primary versus secondary bone healing. Various fixation techniques are covered such as lag screws, plates, intramedullary nails, and external fixation. Reduction techniques both direct and indirect are also reviewed.
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Spondylolisthesis is the forward displacement of one vertebra over another. It is graded from 0-4 based on the Meyerding grading system. Surgical options for spondylolisthesis include decompression without fusion, non-instrumented fusion, instrumented fusion using pedicle screws, and interbody fusions like anterior lumbar interbody fusion (ALIF) or lateral lumbar interbody fusion (LLIF). ALIF provides the advantage of a greater discectomy and sparing of posterior elements but has risks of visceral, ureteral, and vascular injury. LLIF avoids risks to retroperitoneal structures but may require supplemental posterolateral fusion.
This document discusses ACL injuries, including anatomy, biomechanics, mechanisms of injury, classification, clinical examination, diagnostic imaging, risk factors, and treatment options. The ACL attaches the femur to the tibia and prevents anterior tibial translation. Common mechanisms of injury include abduction, flexion, and internal rotation of the femur. Clinical examination involves assessing ligament laxity using stress tests like Lachman and pivot shift. Treatment may involve non-operative rehabilitation, repair if an avulsion fracture is present, or reconstruction using autografts like patellar or hamstring tendons. Proper graft placement and fixation are important for reconstruction to restore knee stability.
This document provides an overview of fractures of the calcaneus bone. It begins with background, noting that calcaneus fractures make up about 2% of fractures and most commonly occur in males aged 21-45 from falls or car accidents. While treatment results have historically been poor, operative fixation can provide better long-term outcomes than conservative care for displaced intra-articular fractures. The document then covers anatomy, classifications, mechanisms of injury, imaging, treatment approaches including closed reduction, open reduction and internal fixation, complications, and take-home points.
The document discusses posterior spine fixation using pedicle screw instrumentation. It provides details on the anatomy of the posterior spine elements and pedicles. Pedicle screw fixation provides a rigid construct that can increase fusion rates and reduce pain. Precise screw placement is important to avoid neurological or vascular injury. Proper preoperative planning and technique are essential to achieve a stable construct and reduce complications.
Pelvic fractures are serious injuries that require prompt evaluation and management. The presentation summarizes the seminar on pelvic fractures, covering relevant anatomy, classification systems, mechanisms of injury, clinical and radiological evaluation, emergency management, and treatment options. Definitive treatment depends on the fracture pattern and stability, ranging from closed reduction and bracing to open reduction with internal or external fixation to address anterior or posterior ring injuries. Complications can include hemorrhage, thrombosis, infection, malunion, and neurological issues.
This document provides an overview of knee anatomy and surgical procedures related to the meniscus, ACL, MCL, PCL, and patellofemoral joint. It begins with meniscal anatomy and function, then discusses factors in meniscal repair versus resection and different repair techniques. Next, it covers ACL anatomy and evidence on surgical treatment. It also discusses anatomy and treatments for MCL, PCL, and posterolateral corner injuries. Finally, it summarizes patellar instability including causes, assessment, and imaging. Key surgical procedures are highlighted throughout like ACL reconstruction techniques and options for cartilage repair.
techniques, methods, indications and complications of various fusion techniques for subaxial cervical spine. comparison of anterior versus posterior techniques, their indications and complication.
Pelvic Ring Fractures document discusses:
1) Pelvic ring fractures present challenges in immediate post-injury stabilization and later definitive management. 2) Fracture stabilization is important for unstable fractures and should be considered part of resuscitation. 3) The pelvic ring is formed by the two innominate bones and sacrum held together by ligaments, and fractures can disrupt this stability.
1. Reconstructive surgeries aim to restore skeletal continuity and function after tumor resection through techniques like arthrodesis, bone grafts, and endoprosthetic replacements.
2. Limb salvage surgery is now possible in 90% of cases due to improved chemotherapy, diagnostics, and surgical techniques. The goal is a painless, functional tumor-free limb.
3. Evaluation includes biopsy, imaging to determine tumor extent and involvement of surrounding structures, staging, and psychosocial/functional assessment. Wide local excision with clear margins while preserving neurovascular structures is key.
1. The cavus foot work-up involves identifying the underlying etiology, whether the deformity is forefoot or rearfoot driven, the plane of the deformity, and if it is rigid or flexible.
2. Common causes of cavus foot include neuromuscular conditions like cerebral palsy and Charcot-Marie-Tooth disease.
3. Treatment depends on the classification - soft tissue procedures for flexible deformities and osteotomies or arthrodesis for rigid ones. Identifying the specific nature of the deformity guides appropriate treatment.
This document provides an overview of anterior cruciate ligament (ACL) injuries, including the functions of the ACL, typical mechanisms of injury, symptoms, signs, diagnostic imaging, natural history if untreated, and treatment options. It discusses the goals of ACL reconstruction surgery, including proper graft selection, placement, tensioning, and fixation. Post-operative rehabilitation is also summarized, with the goal of regaining motion and strength while protecting the graft.
Traumatic knee dislocations are rare injuries that require careful evaluation and management. According to the document, knee dislocations often result from high-energy injuries like motor vehicle collisions or falls. A thorough examination is needed to assess vascular and neurological status. Imaging can identify associated fractures. While some stable injuries may be treated non-operatively, unstable injuries or those with ligament disruption typically require surgical reconstruction. Complications may include neurovascular injuries, infections, and long-term issues like osteoarthritis. Early surgical intervention within 3 weeks of injury may lead to better outcomes compared to delayed treatment.
Trans-facet and trans-laminar screw fixation techniques are described for posterior spinal fixation. Trans-facet screws are directed downward and laterally through the ipsilateral lamina across the facet joint, while trans-laminar screws are inserted bilaterally through the contralateral lamina and facet joints. Trans-laminar screws provide short segment fixation with less hardware and a shorter surgery time compared to pedicle screws, while still achieving adequate stability, especially when used to augment anterior fixation. Indications for these techniques include low grade spondylolisthesis and recurrent disc herniation requiring fusion.
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.
Updated PCL, PLC and Knee Dislocation for Postgraduate Orthopaedic Course in ...Professor Deiary Kader
The document discusses the posterior cruciate ligament (PCL) and posterolateral corner (PLC) of the knee. It provides details on the anatomy, mechanisms of injury, clinical assessment, treatment, and complications for injuries to these structures. For PCL injuries, the strongest ligament in the knee, treatment involves conservative management for isolated acute injuries or reconstruction for chronic symptomatic injuries. For PLC injuries, addressing all injured ligaments is important as isolated treatment can fail. Reconstruction of the lateral collateral ligament, popliteus tendon, and popliteofibular ligament is recommended for chronic complete injuries.
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.
Amputation,Stump care, phantom limb pain and gait training in lower limbHarshita89
1) Phantom limb pain and sensations are perceptions ranging from slight tingling to sharp pain that amputees feel in a limb that is no longer physically attached. It is estimated to affect 49-83% of amputees.
2) There are two main types of pain after amputation - incisional stump pain localized around the scar, and phantom pain felt in the amputated limb itself. Phantom pain can be crushing or tearing.
3) While phantom sensations often occur right after amputation, phantom pain may affect 8-10% of amputees initially but can persist for years in some cases. Stump pain is usually described as pressing, throbbing or burning.
Beverland D. Surgical Factors Influencing RomStruijs
The document discusses several factors that can influence range of motion (ROM) after knee arthroplasty surgery:
1) Surgical technique factors like thoroughly removing osteophytes, restoring proper joint alignment and posterior condylar offset, avoiding excess release of the medial collateral ligament, and closing the surgical wound in extension rather than flexion.
2) Rehabilitation protocols, including early use of continuous passive motion and adherence to post-operative physical therapy.
3) Patient factors such as pre-operative ROM, obesity, and underlying diagnosis of rheumatoid arthritis or osteoarthritis.
4) Potential treatments for stiff knees after surgery include manipulation under anesthesia and revision procedures to address issues like internal rotation of the femoral component
Pelvic fractures account for less than 5% of skeletal injuries but can be life-threatening due to potential for severe blood loss. Imaging like pelvis x-rays and CT scans are used to classify fractures by their mechanism and stability. Treatment depends on the fracture classification but may include pelvic binders, angiography with embolization for bleeding, packing or external and internal fixation for unstable fractures. Early mobilization is preferred over prolonged bed rest to prevent complications.
Pelvic injuries can be life-threatening and require a multidisciplinary approach. Classification systems help determine treatment based on fracture pattern and stability. Hemorrhage control is critical through methods like sheeting, binders, or external fixation. Surgical stabilization may be needed for instability, displacement over 5mm, or open fractures. Non-operative care is appropriate for stable, minimally displaced fractures without posterior injury. Definitive treatment involves open reduction and internal fixation, while external fixation can provide temporary stabilization. Careful preoperative planning considers patient factors and associated injuries.
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Osteoporosis is a progressive bone disease characterized by low bone mass and deterioration of bone tissue, leading to increased bone fragility and risk of fractures. It occurs when bone resorption by osteoclasts exceeds bone formation by osteoblasts. Risk factors include age, gender, genetics, smoking, alcohol, obesity, low vitamin D, and medications like corticosteroids. It is diagnosed using DEXA scans and managed through lifestyle changes, calcium/vitamin D supplementation, and pharmacological therapies like bisphosphonates, strontium, raloxifene, teriparatide, calcitonin, and denosumab. Emerging therapies target mechanisms like cathepsin K, sclerost
This document discusses principles and techniques of internal fracture fixation. It defines common fracture terms like union, delayed union, and nonunion. It describes high versus low energy fractures and different fracture patterns. Key principles of fixation discussed include stability, compression, and healing mechanisms like primary versus secondary bone healing. Various fixation techniques are covered such as lag screws, plates, intramedullary nails, and external fixation. Reduction techniques both direct and indirect are also reviewed.
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Expert Instructor: Brian Tuttle, with over 20 years in Health IT and Compliance Consulting, brings invaluable experience and knowledge, including insights from over 1000 risk assessments and direct dealings with Office of Civil Rights HIPAA auditors.
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Name: Apollo Hospital
Address: Singar Nagar, LDA Colony, Lucknow, Uttar Pradesh 226012
Phone: 08429021957
Opening Hours: 24X7
2. Introduction
Spinal fusion
• The ultimate goal of a fusion is the elimination of
pathologic segmental motion and its accompanying
symptoms
• Achieved by the formation of osseous bridging across the
previously mobile level.
• Successful fusion is known as arthrodesis; nonunion is
referred to as pseudarthrosis .
• Three basic requirements for a successful fusion:
▫ Immobilization,
▫ Fusion bed, and
▫ Bone graft
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3. Landmarks in the History of Fusion
• 1911 -Albee First use of tibial graft
• 1911 -Hibbs First use of Iliac crest graft
• 1953 -Watkins First posterolateral fusion (bilateral
transverse process fusion)
• 1950- Harrington Development of instrumentation (used
to treat pediatric scoliosis from polio)
• 2002 -FDA approval of recombinant human bone
morphogenetic protein-2
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6. Relative Contraindications for Lumbar
Interbody Fusion
• Three level DDD (except in spinal deformity)
• Single level disc disease causing radiculopathy
w/o symptoms of mechanical low-back pain or
instability
• Severe osteoporosis (possible subsidence of
interbody grafts through the end plates)
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7. Types of Spinal Fusion
•Interbody Fusion
•Posterolateral
Fusion
Types
of
fusion
are
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8. Interbody Fusion (IF)
• Removal of the intervertebral disc (discectomy)
and replacement with a bone graft and/or a
device (spacer or cage) to maintain alignment
and disc height.
• The devices usually contain bone graft material
which facilitates fusion.
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10. Posterolateral fusion (PLF)
• Posterolateral fusion places the bone graft
between the transverse processes
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11. Fusion for DDD-goals
Interbody techniques
• Remove pain generator
• Large surface area for fusion
where majority of spinal load
bearing occur
▫ 90% of the surface area
▫ 80% of the load
• Compressive force through
graft
• Correction coronal and sagittal
alignment
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12. Anterior Techniques
Anterior lumbar interbody
fusion (ALIF): disc is
approached from an anterior
(abdominal) incision.
Advantage - avoidance of
cutting muscles of the back.
Disadvantage is the risk of injury
to structures in the abdomen.
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13. Indications -Anterior lumbar interbody
fusion
Degenerative disc disease with or without radiculopathy
Spondylolisthesis
Failed posterior fusion
Scoliosis
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14. Criteria -associated with a good outcome
after ALIF
(1) Axial back pain aggravated by spinal loading
and fusion,
(2) Radiographic studies consistent with disc
degeneration,
(3) Provocative discography that produces pain
only at the affected levels, and
(4) Dynamic studies demonstrating motion/sagittal
deformity on sagittal views.
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21. • With ALIF, an interbody fusion device is used to
redistribute the weight-bearing distribution to the
original ratio.
• According to the Woolf law, the fusion potential
increases if grafts are placed under the direct
compression that supports the placement of the graft
in the anterior column.
Mummaneni PV, Haid RW, Rodts GE. Lumbar interbody fusion: state-of the-art
technical advances. J Neurosurg Spine. 2004;1(1):24-30.
RATIONALE FOR ALIF
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22. • Radiological outcomes, including height restoration
and focal and lumbar lordosis, were superior in
anterior approach, whereas cost, blood loss, and
operative time were greater in ALIF compared with
transforaminal lumbar interbody fusion.
Jiang SD, Chen JW, Jiang LS. Which procedure is better for lumbar interbody
fusion: anterior lumbar interbody fusion or transforaminal lumbar interbody fusion?
Archives of Orthopaedic and Trauma Surgery. 2012;132(9):1259-1266.
RATIONALE FOR ALIF
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23. Anterior lumbar interbody fusion (ALIF)
(A) ALIF interbody device with integral fixation. (B) ALIF implant with anterior plate fixation.
(C) ALIF implant with posterior instrumentation.
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24. Lateral lumbar interbody fusion (LLIF)
• Transpsoas lumbar interbody
fusion (DLIF/direct or
XLIF/eXtreme): the disc is
approached through the psoas
muscle, from an extreme lateral
incision (retroperitoneal) on the
patient’s side.
• The advantage is the avoidance of
back muscles and abdominal
structures required in traditional
fusion procedures.
• The disadvantage is that L5-S1 is
not accessible with this procedure
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25. Indications and Contraindications -lateral
lumbar interbody fusion (LLIF)
• LLIF is most suitable for interbody access from L2 to L4 for
degenerative disc disease with or without instability
• Adjacent segmental disease
• Degenerative spondylolisthesis (grade I or II)
• Complex degenerative scoliotic deformity
contraindications
• LLIF at L5-S1 is generally contraindicated due to obstruction by the
iliac wing.
• Other relative contraindications include grade III or greater
degenerative spondylolisthesis, greater than 30-degree lumbar
deformities
• Bilateral retroperitoneal scarring
• LLIF is generally not used alone when direct posterior
decompression is necessary, such as with lumbar stenosis or disc
rupture
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27. Oblique lumbar interbody fusion (OLIF):
• Oblique lumbar interbody fusion (OLIF): the
disc is approached from a lateral incision on the
patient’s side.
• The procedure is done "obliquely" (in front of
the iliac crest) which gives access to L5-S1
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28. Anterior Approaches - Contraindications
ALIF - Contraindications
• Calcified aorta
• Prior vascular reconstructive
surgery
• Prior intra-abdominal or
retroperitoneal surgery
• History of severe pelvic
inflammatory disease
• Prior anterior spinal surgery
Transpsoas -Contraindications
• At L5/S1 and sometimes at L4/5
because of obstruction from iliac
crest
• Prior retroperitoneal surgery or
scarring
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29. Advantages of OLIF than direct anterior
approach
• Anterior to psoas muscle-avoids
injury to psoas muscle and
lumbar plexus there by less
incidence of cruralgia
• Away from peritoneum and
vasculature ( beware of
ileolumbar vein and transitional
bifircation of great vessels)
• Preserves sympathetic plexus-
decreased incidence of
retrograde ejaculation
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30. Advantages of OLIF....
• Direct visualisation and
discectomy, easy to do
end plate preparation
• Can be performed L2-L3
to L4-L5
• Upto 3 level fusion can be
done using 4 cm incion by
“sliding window”
technique
Rodgers WB, Gerber EJ, Patterson J. Intraoperative and early postoperative complications in
extreme lateral interbody fusion: an analysis of 600 cases. Spine (Phila Pa 1976) 2011;36:26-32.
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31. Advantages of OLIF
• Lesser incidence of hernias and ileus
• Decreased blood loss
• Increased surface area of the OLIF cage which is 3
times more than TLIF cage gives better and strong
arthodesis
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32. Advantages of anterior approach
• nerve root retraction and entrance into the spinal canal
are unnecessary, thereby eliminating epidural scarring
and perineural fibrosis
Chung SK, Lee SH, Lim SR, et al. Comparative study of laparoscopic L5-S1 fusion versus open
mini-ALIF, with a minimum 2-year follow-up. Eur Spine J. 2003;12 (6):613-617
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33. Advantages Anterior Approaches
• Larger graft
placement without
manipulation of
nerve roots
• Deformity
correction
• Indirect
decompression
• Greater fusion
surface area
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35. ALIF - Complications
• Retrograde ejaculation
▫ Most series < 1% to 7%
▫ Much higher (10 times) with transperitoneal
approaches and with laparoscopic approaches
• Blunt dissection versus electrocautery
• Large majority of patients recover within 6 – 12
months
• Bowel & Ureter injury
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36. Extreme Lateral - Complications
• Reporting of complications has been inconsistent 3% -
60%)
• Genitofemoral, ilioinguinal or lateral femoral cutaneous
nerve injuries -Thigh numbness, paresthesias
• Femoral nerve -Leg weakness
• Damage to lumbosacral plexus which progressively
migrates anteriorly beginning at L1/2 level
• Psoas muscle injury and pain
• Traction injury to plexus postop dysesthesias
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37. Posterior Lumbar Interbody Fusion (PLIF)
• The first successful report of a posterior lumbar
interbody fusion (PLIF) dates to 1940 by Cloward
Indications
• Recurrent disc herniation
• Failed back surgery syndrome
• Spondylolisthesis
• Bilateral midline disc herniation
• Segmental instability
• Degenerative disc disease
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38. Posterior Lumbar Interbody Fusion (PLIF)
Contraindications to performing PLIF include
• Osteoporosis,
• Discitis,
• Subchondral sclerosis, and
• Adhesive arachnoiditis.
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39. The classic PLIF technique consists of three surgical
steps:
(1) Laminectomy or laminotomy with partial or
complete facetectomy,
(2) Removal of the intervertebral disc, and
(3) Fusion
Posterior interbody techniques (PLIF)
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41. Posterior interbody techniques (PLIF)
A, The nerve root and dural sac are
retracted medially, creating maximal
exposure of the interbody space.
B, The interbody device is inserted
bilaterally and packed with bone for
maximal fusion.
C, A pedicle screw is used to distract
the disc space. The trajectory and
depth of the screw are important for
successful fusion.
D, Next, using either a screw or a
rod construct, the final arthrodesis
is reinforced until biologic fusion
is achieved.
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42. Complications of PLIF
PLIF is a technically challenging and demanding procedure and
consequently is associated with complications.
• Nerve root injury
▫ The nerve root that exits at the level above the disc space often
lies near the interbody graft as it is being placed and can easily
be injured.
• Incidental durotomy
• Wrong -level surgery,
• Adjacent-level disease,
• Graft retropulsion, and pseudarthrosis in the case of
instrumentation with PLIF.
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43. Lumbar – Transforaminal Lumbar Interbody
Fusion (TLIF)
• Transforaminal lumbar interbody fusion (TLIF)
reestablishes anterior column support while allowing for
posterior fixation, thereby imparting improved fusion
rates because of circumferential support.
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44. Lumbar – Transforaminal Lumbar Interbody
Fusion (TLIF)
Indications
• Degenerative disc disease,
• Low-grade spondylolisthesis
• Synovial cysts (when fusion is required)
• Multiply recurrent disc herniations, and foraminal stenosis
associated with deformity.
• TLIF is ideal for grade I or II spondylolisthesis with unilateral
symptoms.
Contraindicated in
• Complete disc desiccation
• Presence of extensive osteophytes- limits disc distraction.
• Extensive scarring from prior posterior surgery serves as a
relative contraindication.
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45. TLIF utilizes an imagined
quadrangular space between
the transverse processes
of the vertebral bodies
adjacent to the affected disc
space and the traversing
nerve root medially
Lumbar – Transforaminal Lumbar Interbody
Fusion (TLIF)
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46. Lumbar – Transforaminal Lumbar Interbody
Fusion (TLIF)
• TLIF is performed to remove a portion of a disc that is
the source of back or leg pain.
• Bone graft is used to fuse the spinal vertebrae after the
disc is removed.
• However, the TLIF procedure places a single bone graft
between the vertebrae from the side, rather than two
bone grafts from the rear as in the PLIF procedure.
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47. Lumbar – Transforaminal Lumbar Interbody
Fusion (TLIF)
Decompression Removing the facet joint and disc relieves pressure on the
compressed spinal nerve, allowing it to return to the proper
position.
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48. Lumbar – Transforaminal Lumbar Interbody
Fusion (TLIF)
Graft Placement
A single bone graft is placed in the
disc space from the lateral
Preparing for Fusion a motorized instrument is
used to remove the top (cortical) layer of the
transverse processes
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49. Lumbar – Transforaminal Lumbar Interbody
Fusion (TLIF)
The rod and screw instrumentation
provides stability to the spine
Bone Graft
Bone grafting can be done with pieces of a patient’s own
bone (autograft), processed bone from a bone bank
(allograft), or a bone graft substitute (demineralized
bone,ceramic extender, or bonemorphogenetic protein).
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50. Complications -TLIF
• The most frequent include blood loss requiring
transfusion
• Lumbar wound infection
• Postoperative radiculitis,
• Cage subsidence or extrusion, and pseudoarthrosis
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52. Posterior interbody techniques (PLIF TLIF) •
Problems
• Graft size vs. nerve root injury vs endplate fracture
• Suboptimal restoration of disc height and surface area
for fusion
• Poor visualization of disc space/endplates
• Limited endplate preparation for fusion
• Endplate damage/fractures graft subsidence
• Time
• Blood loss
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53. TLIF- advantages
• TLIF obviates the morbidity from the retroperitoneal
dissection and subsequent posterior fixation required from
anterior lumbar interbody fusion (ALIF).
• Unlike PLIF, TLIF requires minimal to no retraction on the
thecal sac and nerve roots while still providing 360 degrees
of support.
• Because TLIF utilizes a more lateral trajectory, it can be
performed in the setting of previous surgery with
identifiable landmarks and a cleaner plane of dissection.
• The average length of stay for both minimally invasive and
open TLIF ranged between 3 and 6 days
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54. Posterolateral fusion (PLF)
• Posterolateral fusion places the bone graft between the
transverse processes (the bony protuberances on the
vertebrae) rather than the intervertebral disc space,
which is left intact.
• The approach is through a posterior (back) incision, and
a laminectomy is typically required to gain access.
• PLF is usually accompanied by fixation.
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55. Posterolateral
fusion (PLF)
The landmarks used
for cannulating the
pedicles are the
meeting point of the
pars interarticularis,
the superior
articulating process,
and the transverse
process
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56. Complications open posterior lumbar
fusion
• Mortality rates have been found to be 0.15% to 0.29%.
• The most common preventable cause of death- analgesia overuse
Short term complications
• Surgical site infections, are among the most common.
• Incidental durotomy causing a cerebrospinal fluid leak,
• Spinal epidural hematoma,
• Cauda equina syndrome,
• Neurologic injury,
• Rhabdomyolysis, and sudden vision loss
Long-term complications
• Pseudarthrosis,
• Chronic pain from the donor allograft site.
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57. Advantages of Lumbar Interbody Fusion
Compared with Posterolateral Fusion
• Interbody grafts are compressed by 80% of spinal
loads, whereas posterolateral grafts are compressed by
20%
• Interbody grafts occupy 90% of intervertebral surface
area, whereas posterolateral grafts occupy only 10%.
• The interbody space is more vascular than the
posterolateral space, increasing chances for fusion.
• Interbody grafts can better restore coronal and sagittal
balance.
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61. Post op
• VAS -1
Restoration of disc
space height
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62. Key points…..
• Both anterior and posterior approaches for interbody fusion are associated with
good fusion rates and outcomes in patients with symptomatic lumbar degenerative
disease.
• Anterior approaches allow better access to and visualization of the disc and
endplates which facilitate:
▫ More complete discectomy
▫ Larger surface area for fusion
▫ Better endplate preparation
▫ Larger graft placement for disc height restoration and lordosis
• With a good access surgical team, the complications associated with ALIF are
minimal
• Extreme lateral interbody fusion is a relatively new procedure. As surgeons
become more proficient in the operation and as surgical technique is refined,
sensory dysesthesias and psoas trauma associated with the procedure are
becoming less prevalent.
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63. • OLIF is a minimally invasive fusion procedure
• Lesser complication rate when compared to ALIF
• Longterm follow up (5 and half years)of patients with
OLIF showed similar outcome as that ALIF with
lesser morbidity
Saraph V, Lerch C, Walochnik N, Bach CM, Krismer M, Wimmer C. Comparison of
conventional versus minimally invasive extraperitoneal approach for anterior
lumbar interbody fusion. Eur Spine J 2004;13:425-31.
Key points…..
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