1. Robotic total knee arthroplasty (TKA) uses preoperative imaging and intraoperative robotics to improve the accuracy of implant positioning and soft tissue balancing compared to conventional jig-based TKA.
2. Earlier robotic systems were associated with technical complications in up to 30% of cases, but complication rates with newer systems, such as Mako and Navio, appear to be low.
3. Robotic TKA systems can be classified as passive, active, interactive, or teleoperated based on their level of autonomy and interaction with the surgeon. The most widely used interactive systems currently are Mako, Navio, Rosa, and Cori.
Discuss approaches to the knee and Describe in detail TKRSoliudeen Arojuraye
This document discusses approaches to the knee joint and describes the operation of total knee arthroplasty (TKA) in detail. It outlines various approaches to the knee including medial para-patellar, subvastus anteromedial, and anterolateral approaches. It then describes the operative technique of TKA, including preoperative planning, bone cuts of the femur and tibia using cutting guides, and the importance of soft tissue balancing and implant fixation for achieving good results.
This document discusses peripheral nerve injuries. It begins by describing the structure and components of peripheral nerves. It then discusses the signs and symptoms of different types of peripheral nerve injuries like radial nerve, ulnar nerve and median nerve palsies. The document also covers the pathophysiology of nerve injury including Wallerian degeneration. It describes the diagnostic tools like electrodiagnostic studies and various treatment options for peripheral nerve injuries including nerve repair techniques.
1. Robotic total knee arthroplasty (TKA) uses preoperative imaging and intraoperative robotics to improve the accuracy of implant positioning and soft tissue balancing compared to conventional jig-based TKA.
2. Earlier robotic systems were associated with technical complications in up to 30% of cases, but complication rates with newer systems, such as Mako and Navio, appear to be low.
3. Robotic TKA systems can be classified as passive, active, interactive, or teleoperated based on their level of autonomy and interaction with the surgeon. The most widely used interactive systems currently are Mako, Navio, Rosa, and Cori.
Discuss approaches to the knee and Describe in detail TKRSoliudeen Arojuraye
This document discusses approaches to the knee joint and describes the operation of total knee arthroplasty (TKA) in detail. It outlines various approaches to the knee including medial para-patellar, subvastus anteromedial, and anterolateral approaches. It then describes the operative technique of TKA, including preoperative planning, bone cuts of the femur and tibia using cutting guides, and the importance of soft tissue balancing and implant fixation for achieving good results.
This document discusses peripheral nerve injuries. It begins by describing the structure and components of peripheral nerves. It then discusses the signs and symptoms of different types of peripheral nerve injuries like radial nerve, ulnar nerve and median nerve palsies. The document also covers the pathophysiology of nerve injury including Wallerian degeneration. It describes the diagnostic tools like electrodiagnostic studies and various treatment options for peripheral nerve injuries including nerve repair techniques.
This document discusses hip prosthesis replacements and issues related to them. It includes a link to information on dislocated hip prostheses from an orthopedic radiology site. It also links to a Fortune article about a $1 billion verdict against Johnson & Johnson related to faulty hip implants.
Minimally invasive total hip replacementTunO pulciņš
Minimally invasive total hip replacement (MITHR) uses a smaller incision of 6-10 cm compared to the standard incision. While MITHR results in less soft tissue damage and shorter hospital stays, it also has a longer learning curve for surgeons. Early in the learning curve, complication rates are higher for MITHR. With increased experience, surgeons can perform MITHR with outcomes equivalent to conventional THR. However, the evidence does not clearly support making MITHR the standard procedure over the conventional approach. Patient characteristics and surgeon experience should guide the choice of surgical approach.
Cemented versus uncemented fixation in total hip replacementTunO pulciņš
The document discusses and compares cemented versus uncemented fixation techniques in total hip replacement (THR). Cemented fixation uses acrylic polymer to lock the bone and implant together, while uncemented implants have rough, porous coatings to allow bone ingrowth. Some advantages of cemented fixation are that it is more suitable for obese patients, has a better outcome for displastic hips, and is better for patients with osteoporosis. However, uncemented fixation has a lower revision rate within 10 years, a low risk of femoral loosening once stable fixation occurs, and does not commonly cause osteolysis. Both techniques have benefits depending on the individual patient's needs.
Anterior cruciate ligament reconstruction- allograft versus autograftTunO pulciņš
1. The document compares allograft versus autograft options for anterior cruciate ligament (ACL) reconstruction surgery. Allografts use donor tissue while autografts use the patient's own tissue.
2. There are several factors to consider for each graft including patient characteristics, surgical factors, biological incorporation, and the risk of disease transmission. Younger, high-demand athletes often due better with autografts which incorporate faster and have lower re-tear rates.
3. However, allografts can be preferable for older, lower-demand patients due to benefits like avoiding donor site morbidity and faster return to activities of daily living. Overall graft selection requires weighing these various patient and graft-specific
Presacral venous plexus bleeding in patients with pelvic fracturesTunO pulciņš
1. The document discusses presacral venous plexus bleeding in patients with pelvic fractures and various methods to stop the bleeding.
2. Techniques used to stop bleeding include pelvic packing, use of sterile metallic thumbtacks, cauterization, suturing, and ligating bleeding vessels.
3. Damage control resuscitation principles are also described, including permissive hypotension, blood product transfusion in a 1:1:1 ratio, and rewarming.
Damage control surgery is a technique used for seriously injured patients that prioritizes short-term physiological recovery over anatomical reconstruction. It involves abbreviated laparotomy to control bleeding and contamination, followed by intensive care resuscitation to correct hypothermia, coagulopathy, and acidosis, and then definitive surgery within 36-48 hours. The goal is to prevent the "lethal triad" of hypothermia, acidosis, and coagulopathy that can lead to multiple organ failure and death in trauma patients.
6. Anatomija II
Mugurējais artikulārais nervs,
zars no tibiālā nerva, inervē
PKS
Nervu šķiedras starp kūlīšiem
sāpju pārvadei
Mehanoreceptori
piestiprināšanās vietās (īpaši
pie femorālā gala)
N. tibialis
8. Posterolaterālais kūlītis
nodrošina galveno
pretestību hiperektenzijai
Anteromediālais kūlītis
stingrāks fleksijā
9. Anamnēze
Klasiski – bezkontakta palēnināšanās, lēkšana vai
«atspoles» kustība
Aksiāla rotācija, hiperfleksija, varus vai valgus
pārslodze un rotācija
Parasti celis hiperekstenzijā vai «izlecis» no nocītavas
un tad reponējies
Klikšķis
Ārēji spēki
10. Nespēj piecelties, lielas sāpes
Dažās stundās tūska
Aspirējot hemartroze (Dg 70%)
11. Fizikāla izmeklēšana
Labāk pirms tūskas, sāpēm, hemartrozes, muskuļu
rezistences
Lachman tests (95% sensitivitāte)
Pivot shift tests (atslābis pacients, intakta med. saite)
Priekšējais atvilknes tests
[https://www.youtube.com/watch?v=vEQw-G1Vr18]
Artrometrs (KT-1000/2000)
Pārbauda arī MKS ar Godfrey testu
Pārbauda mediālo kolaterālo saiti
14. Saites sastiepuma pakāpes
Grade 1 Sprains. Mazliet sastiepta, spēj saglabāt
locītavas stabilitāti
Grade 2 Sprains. Sastiepta tā, ka pēc tam ir
vaļīgāka
Grade 3 Sprains. Pilns pārrāvums, ceļgala
nestabilitāte
Daļēji pārrāvumi ir reti!
15. Pavadošās traumas
Mediālās kolaterālās saites bojājums
parasti menedžē konservatīvi līdz pilnai MCL sadzīšanai
un tikai tad var domāt par PKS rekonstrukciju.
Meniska bojājumus - ja meniska plīsuma veids, tips
to pieļauj menisks ir jāšuj obligāti
Sīki tibijas plato mugurēji margināli lūzumi un vai
kaulu tūska jeb trabekulāri lūzumi menedžējami
konservatīvi - pacients uz kruķiem
17. Konservatīvi?
Intensīva rehabilitācija
Dzīvesveida pārmaiņas,
aktivitāšu ierobežošana ar
nestabilitātes risku
• Funkcionālas ceļa ortozes lietošana ir
kontroversāla un nedod vēlamu
rezultātu saistībā ar atkārtotu traumu
pie sporta
18. Indikācijas operācijai
Simptomātiska ceļgala locītavas nestabilitāte
Nestabils un operējams meniska bojājums
kombinācijā ar PKS nepietiekamību
PKS rekonstrukcija var novērst citu struktūru
bojājumu, kas var rasties nākamo ceļgalu traumu
dēļ
Kontraindikācijas – aktīva infekcija, mīksto audu
abrāzija, pacienta nevēlēšanās piedalīties
kompleksā rehabilitācijā
19. Neapmierinoši rezultāti
sašujot kopā vidusdaļā plīsušu
PKS
Pie kaula avulsijas kaula
fragmentu var fiksēt ar šuvēm
vai skrūvēm
20. Izolēta ekstraartikulāra rekonstrukcija dod
neapmierinošus rezultātus
Lieto reti kopā ar intraartikulāro rekonstrukciju pie
lielas varus deformācijas un locītavas kapsulas
elementu funkcionāla trūkuma laterālajā pusē
21. Artroskopiska rekonstrukcija
Artroskopiskas rekonstrukcijas tehnikas ir ar nelielu
pārākumu salīdzinot ar miniartrotomiju, lielākoties
agrāku postoperatīvo sāpju mazināšanās dēļ
Vēlama pacienta atgūšanās no traumas pirms
operācijas:
mazinās tūska,
atgriežas pilns ROM,
aktīvas kustības,
iespējama pilna ekstenzija
22. Transplantāta izvēle
Autotransplantātu izvēle – mazs risks nelabvēlīgai
iekaisuma reakcijai, nav slimību transmisijas risks
Nekroze
Revaskularizācija
Šūnu proliferācija
Remodelācija
24. BTB
Bone-tendon-bone
BTB – 8-11mm plats
Vidējā patelārās saites 1/3
Kaula fragmenti
Stingra fiksācija
Ātrāka ieaugšana
Stingrs transplantāts
Sāpes, mm. vājums
25. Hamstring
Hamstring cīpslu transplantāts kļūst populārāks
relatīvi mazā donora vietas traumatisma dēļ
Trīsdaļīgs vai četrdaļīgs transplantāts
Iespējams bioloģiskāka slodzes sadale pēc
transplantācijas
Trūkumi – iespējama nevēlama dzīšana kaulu
tuneļos un trūkst stingra kaulaina fiksācija
26.
27. Kvadricepsa cīpsla
Izolēta cīpsla vai ar patellas
daļu
Vājāka biomehāniskā
izturība par iepriekšējiem
Alternatīva izvēle, iespēja
pie revīzijām, traumām ar
multiplu saišu bojājumu
28. Sintētiski materiāli
Nav daudz pētījumu par ilgtermiņa rezultātiem
Dārgi
Nav donora, ātrāka operācija
Ātrāka rehabilitācija
Leeds-Keio
29. Allografts
Nav donora vietas bojājums
Īsāks operācijas laiks
Mazāki griezieni
Slimību pārnese!
Vājāks transplantāts
34. Pēcoperācijas režīms, rehabilitācija
Mērķis – atjaunot normālas locītavas kustības un spēku,
saudzējot transplantātu
Pēc operācijas pretsāpju līdzekļi, aukstuma aplikācijas,
imobilizācija (1 – 4 dienas). TŪLĪTĒJA EKSTENZIJA
Imobilizācija staigāšanas un miega laikā (2 – 4) nedēļas
Pārvietošanās ar kruķiem ar daļēju svara nešanu 2 – 4
nedēļas
Pēcoperācijas spēka treniņi (svara spiešana) pirmajās 2
nedēļās
Ārstnieciskā vingrošana līdz gadam
Parasti atgriežas iepriekšējā aktivitāšu līmenī pēc 4-6
mēn.
35. Pilnīgi drīkst noslogot operēto celi:
Pilnīgi atjaunojas kustības
KT1000 2-3 mm salīdzinot ar veselo pusi
Vismaz 85% no četrgalvainā muskuļa spēka un
pilnīgs paceles muskuļa spēks
Vismaz 85% muskuļu spēks, salīdzinot ar otru kāju
36. Paldies par uzmanību!
Avoti:
Sobotta Atlas of Human Anatomy 14th ed.
Orthopedic Principles – a Resident’s Guide 2005
Campbell’s Operative Orthopedics 12th ed.
Current Essentials Orthopedics
«Single- versus Double-bundle ACL Reconstruction:
Is There Any Difference in Stability and Function at
3-year Followup?» Alberto Gobbi, Vivek Mahajan,
Georgios Karnatzikos, Norimasa Nakamura
Editor's Notes
PKS stiprinās tibiālajā plato, mediāli no laterālā meniska priekšējā raga piestiprināšanās vietas padziļinātā vietā anterolaterāli no anterior tibial spine
Tibiālā piestiprināšanās vieta ir lielāka un vairāk stingra, droša kā femorālā
Primārā asinsapgāde nāk no vidējās ceļgala artērijas, kura caur mugurējo locītavas kapsulu iekļūst starpkondiļu notch tuvu femorālajai piestiprināšanās vietai
Papildus apgāde nāk no retropatellāra tauku maisiņa caur apakšējo mediālo un laterālo ceļgala artēriju
anteromedial band is tight in flexion, providing the
primary restraint,
posterolateral bulky portion of
this ligament is tight in extension.
Propriorecepcija – locītavas posturālais stāvoklis
Increased excursion relative to the opposite knee and absence of a firm end point suggest an injury to the
anterior cruciate ligament. Lachman testā
(KT-1000/2000) (documentation of surgical resultsboth intraoperatively and postoperatively)
Increased excursion relative to the opposite knee and absence of a firm end point suggest an injury to the
anterior cruciate ligament. Lachman testā
It has been well documented that an individual with an anterior cruciate ligament–deficient knee who resumes athletic activities and has repeated episodes of instability will sustain meniscal tears and osteochondral injuries that eventually lead to arthrosis.
Bez PKS – meniska bojājumi – osteohondrāli bojājumi - artroze
Possible causative factors for the increased incidence in women may be extrinsic (body movement, muscle strength, shoe-surface interface, and skill level) or intrinsic (joint laxity, hormonal influences, limb alignment,notch dimensions, and ligament size). Female sex hormones (i.e., estrogen, progesterone, and relaxin) fluctuate radically during the menstrual cycle and are reported to increase ligamentous laxity and to decrease neuromuscular performance.
Souryal and Freeman formulated the notch width index, which is the ratio of the width of the intercondylar notch to the width of the distal femur at the level of the popliteal groove measured on a tunnel view radiograph of the knee (Fig. 45-101). The normal intercondylar notch ratio was 0.231 ± 0.044
Vīriešiem lielāks
BTB This graft’s attractive features include its high ultimate tensile load (approximately 2300 N), its stiffness (approximately 620 N/mm),
Patellārās saites iztrūkstošā vieta ataug
6-8 nedēļas līdz integrācijai
has an ultimate tensile load reported to be as high as 4108 N.
Approximately 10-12 weeks to heal to bone.
Abstract
BACKGROUND:
Despite a number of studies comparing postoperative stability and function after anatomic double-bundle and single-bundle anterior cruciate ligament reconstruction (ACLR), it remains unclear whether double-bundle reconstruction improves stability or function.
QUESTIONS/PURPOSES:
We therefore asked whether patients having single- and double-bundle ACLR using semitendinosus (ST) alone differed with regard to (1) postoperative stability; (2) ROM; and (3) five functional scores.
METHODS:
We prospectively followed 60 patients with an isolated anterior cruciate ligament (ACL) injury. Thirty patients underwent single-bundle and 30 patients underwent double-bundle ACL reconstruction. Clinically we assessed stability and range of motion (ROM); anteroposterior stability was assessed by Rolimeter and rotational stability by a pivot shift test. Function was assessed by IKDC, Noyes, Lysholm, Marx, and Tegner activity scales. The minimum followup was 36 months (mean, 46.2 months; range, 36-60 months).
RESULTS:
Residual anteroposterior laxity at 3 years postoperatively was similar in both groups: 1.4 ± 0.3 mm versus 1.4 ± 0.2 mm, respectively. We observed no difference in the pivot shift test. ROM was similar in both groups, although double-bundle patients required more physical therapy sessions to gain full ROM. IKDC, Noyes, Lysholm, Marx, and Tegner scores were similar at final followup.
CONCLUSION:
Double-bundle reconstruction of the ACL did not improve function or stability compared with single-bundle reconstruction.
LEVEL OF EVIDENCE:
Level II, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.