Tibial cut is a crucial step in ensuring adequate and appropriate proximal tibial resection for mechanical orientation and axis in total knee replacement. We evolved the concept and technique of Condylar Differential for planned tibial cuts in conventional total knee replacement, which accounts for individual variations and reflects individual mechanical orientation and alignment. We used Condylar Differential in 37 consecutive total knee replacements including valgus knees and severe advanced osteoarthritis. First a vertical line is drawn on digital weight bearing anteroposterior radiograph for mechanical axis of tibia. Then a horizontal line is drawn across and perpendicular to the mechanical axis. The distances between the horizontal line and the lowest reproducible points of articular surfaces of medial and lateral tibial condyles respectively are measured. The difference between two measurements obviously represents Condylar Differential. Condylar Differential, adjusted to the nearest millimetre, is maintained in executing tibial cuts, successively if necessary. Condylar Differential measurement showed a very wide variation, ranging from 8–6 (2 mm) to 10-0 (10 mm). We found that prior measurement of Condylar Differential is a simple, consistent and effective estimate and individualises the tibial cut for optimal templating of tibia. We encountered no problems, adopting this technique, in our series. Condylar Differential contributes to optimal individualised tibial cut in conventional total knee replacement and is a useful alternative to computer navigated option with comparable accuracy in this respect. While we used the technique in digitised radiographs, this technique can also be applied to plain films, allowing for magnification.
DAIR procedure is well established for Prosthetic Joint Infection (PJI) in acute setting after total hip and knee replacements. We present our experience of DAIR following hip and knee replacements in a District General Hospital (DGH), where we delivered comparable results to leading tertiary centres in short to mid-term followup. We undertook a retrospective study involving 14 patients, who underwent DAIR in our DGH between August 2012 and December 2015. Patient cohort included primary, complex primary and revision hip and knee replacements. Microbiological support was provided by a Microbiologist with interest in musculoskeletal infections. 14 patients [9 males, 5 females; age 62 to 78 years (Mean 70.7); BMI 22 to 44.2 (Mean 33.8)] with multiple comorbidities underwent DAIR procedure within 3 weeks of onset of symptoms. 12 out of 14 grew positive cultures with two growing Vancomycin resistant Enterococci. Intravenous antibiotics were started after multiple samples intraoperatively and continued in six patients after discharge, while 8 were discharged with oral antibiotics. One patient died of overwhelming intraoperative septic shock in postoperative period. Another patient died of myocardial infarction subsequently. 12 (85.7%) patients were doing well with regular followup (Mean 20 months). With good patient selection, DAIR is a far simpler solution and a safe and reproducible surgical option for early PJI following hip and knee replacements compared to one or two stage revisions. But published data in contemporary literature is predominantly from specialised centres. Our small series provides a perspective of comparable early to mid-term results of DAIR from DGH.
Stress fractures at tracker after computer navigated total knee replacement are rare. Periprosthetic fracture after Minimally Invasive Plate Osteosynthesis (MIPO) of stress fracture through femoral tracker is unique in orthopaedic literature. We are reporting this unique presentation of periprosthetic fractures after MIPO for stress fracture involving femoral pin site track in computer assisted total knee arthroplasty, treated by reconstruction nail (PFNA). A 75-year old female, who had computer navigated right total knee replacement, was admitted 6 weeks later with increasing pain over distal thigh for 3 weeks without trauma. Prior to onset of pain, she achieved a range of movements of 0–105 degrees. Perioperative radiographs did not suggest obvious osteoporosis, pre-existent benign or malignant lesion, or fracture. Radiographs demonstrated transverse fracture of distal third of femur through pin site track. We fixed the fracture with 11-hole combihole locking plate by MIPO technique. Eight weeks later, she was readmitted with periprosthetic fracture through screw hole at the tip of MIPO Plate and treated by Reconstruction Nail (PFNA), removal of locking screws and refixation of intermediate segment with unicortical locking screws. Then she was protected with plaster cylinder for 4 weeks and hinged brace for 2 months.Background
Methods
Mechanics and kinematics of the knee following total knee replacement are related to the mechanics and kinematics of the normal knee. Restoration of neutral alignment is an important factor affecting the long-term results of total knee replacement. Tibial cut is a vital and crucial step in ensuring adequate and appropriate proximal tibial resection, which is essential for mechanical orientation and axis in total knee replacement. Tibial cut must be individually reliable, reproducible, consistent and an accurate predictor of individual anatomical measurements. Conventional tibial cuts of tibia with fixed measurements cannot account for individual variations. While computer navigated total knee replacement serves as a medium to achieve this objective, the technology is not universally applicable for differing reasons. Therefore we evolved the concept and technique of Condylar Differential for planned tibial cuts in conventional total knee replacement, which accounts for individual variations and reflects the individual mechanical orientation and alignment. We used the Condylar Differential in 37 consecutive total knee replacements. We also applied the technique in valgus knees and severe advanced osteoarthritis. First a vertical line is drawn on the digital weight bearing anteroposterior radiograph for mechanical axis of tibia. Then a horizontal line is drawn across and perpendicular to the mechanical axis of tibia. The distances between the horizontal line and the lowest reproducible points of the articular surfaces of the medial and lateral tibial condyles respectively are measured. The difference between the two measurements obviously represents the Condylar Differential. Condylar Differential, adjusted to the nearest millimeter, is maintained in executing the tibial cuts, if necessary successive cuts.Background
Methods
Debridement, Antibiotics and Implant Retention (DAIR) procedure is well established for Prosthetic Joint Infection (PJI) in acute setting after total hip and knee replacements. We present our perspective of DAIR in a relatively a small cohort following hip and knee replacements in a District General Hospital (DGH) in United Kingdom, where we delivered comparable results to leading tertiary centers in short to mid-term followup. We undertook a retrospective study involving 14 patients, who underwent DAIR in our DGH between August 2012 and December 2015. Patient cohort included primary, complex primary and revision hip and knee replacements. Multiple samples were taken intraoperatively for cultures and histology. mMicrobiological support was provided by a microbiologist with interest in musculoskeletal infections.OBJECTIVE
METHODS
Debridement Antibiotics Implant Retention (DAIR) is a recognised procedure in the management of acute prosthetic joint infection (PJI). We present an experience of DAIR following hip and knee replacements in a District General Hospital. A retrospective review of 14 patients who underwent DAIR procedures between August 2012 and December 1015 were collated. The cohort included primary, complex primary and revision hip and knee replacements. All patients received multidisciplinary care with surgery performed by one of two arthroplasty surgeons. 9 males and 5 females with age 62 − 78 years (Mean 70.7) and BMI 22–44.2 (Mean 33.8) with various co-morbidities underwent DAIR. Surgical criteria required DAIR to be performed within 3 weeks of the onset of symptoms of infection. The time from index surgery however ranged from 15 days to 58 months. 12 of 14 grew positive cultures including two growing Vancomycin Resistant Enterococcus. Intravenous antibiotics were commenced after intraoperative samples and tailored OPAT. Antibiotic schedule varied from six weeks to eight months. 12 (85.7%) patients remain under follow up. Mean follow is 20 months (RANGE 6months-3years10months) with no recurrence of infection or reoperation. With appropriate patient selection, DAIR is safe and reproducible surgical option in PJI in hip and knee replacements, avoiding the implications of a one or two stage revision. Published Data in contemporary literature is predominantly from specialised centres. Our small series provides a perspective of early to mid term results of DAIR to DGH. Interestingly each procedure is categorised as a failed implant on the National Joint Register.
Current literature of definition, classification and outcomes of fractures of talar body remains controversial. Our primary purpose is to present an unusual combination of fractures of talar body with pantalar involvement / dislocation / extension as a basis for modification of Müller AO / OTA Classification. We include four consecutive patients, who sustained talar body fractures with pantalar subluxation/dislocation /extension. These unusual injury patterns lead us to reconsider Müller AO / OTA Classification in the light of another widely used talar fracture classification, Hawkins Classification of fractures of neck of talus and subsequent modification by Canale and Kelly.Background
Methods
Two perceived weaknesses of Intramedullary Referencing of Tibia are crucial:
difficulties in understanding where centre of medullary canal projects on the plateau to plan entry hole in bowing of tibia, technical axis differs from anatomical axis, resulting in varus placement of tibial tray. We evolved two technical pointers for optimal Tibial Intramedullary Referencing. We undertook a retrospective study to analyse feasibility of our technique of Tibial Intramedullary Referencing.
Entry Drill Hole is made to a depth of 2–3 cm only and intramedullary rod is passed to find its own way into canal. This avoids tilted position of rod forced by a deeper drill hole and minimises tilted or wrongly sloped position of tibial tray. Identification of Entry Point is facilitated by clearing soft tissue at tibial attachment of ACL over intercondylar eminence and confirmed by placing distal phalanx of surgeon’s thumb over bare area of anterior tibial plateau. Entry point is usually at the tip of thumb. We encountered no problems by our technique in Tibial Intramedullary Referencing in 204 Total Knee Replacements.
Methods &
Results: We treated concomitant dorsal dislocation of first metatarsophalangeal joint and divergent Lisfranc fracture-dislocation in an intoxicated patient as a heavy weight fell on foot. Closed reduction of first metatarsophalangeal joint was unstable until after open reduction and fixation of first tarsometarsophalangeal joint. First to third tarsometatarsal joints were stabilised with cannulated screws and lateral two rays with Kirschner wires. Prophylactic fasciotomies were performed to preempt potentially high risk of failure of recognition of compartment syndrome in intoxicated patient. Clinical pathodynamic analysis suggests that natural tendency to withdraw the foot contributed to primary medial loading with forced hyperextension of hallux metatarsophalangeal joint and enhanced complementary hyperflexion of midfoot. The former resulted in dorsal dislocation of first metatarsophalangeal joint. Then load shift toward secondary axis of lateral divergent loading became the operative force to produce divergent Lisfranc dislocation, which effectively resulted in a floating forefoot. Conclusions: Floating forefoot is a unique injury after high-energy trauma, although floating metatarsal and association between Jahss Type I complex dislocation of first metatarsophalangeal joint and Lisfranc injury were described. Floating forefoot also represents Grade V in the modified classification of metarsophalangeal injuries (Kodali Siva R K Prasad et al Modification of Clanton’s classification) as progression of injury pattern transcends the local barrier and raises the spectrum of dynamic cascade of multidirectional transmission of the operative forces with the resultant unique injury.
In Group I, two main sets of trabeculae were observed. The first set consists of three bundles, which arise from anterior cortex and support subchondral area – the posterior third bundle curves and spreads to posterior cortex of olecranon. The second set arises from posterior cortex and terminates under subchondral area. In Group II, trabeculae subtend a 900 angle to articular surface. CT scans of 8 patients (Group III), originally performed for investigation of fractures of radial head, ascertained real-life trabecular pattern of olecranon and confirmed cadaveric observations.
We undertook a retrospective study to evaluate Notch Trial by the frequency of the need to remove osteophytes or file uneven surfaces in intercondylar resection by using detachable box part of trial femoral component and occurrence of distal femoral intercondylar fractures.
frequency of osteophyte removal or filing uneven surfaces in intercondylar resection and distal femoral intercondylar fractures intraoperatively or on postoperative radiographs. We had to remove osteophytes and file cut surfaces in 183 (88.88%) patients after Notch Trial. We had no distal femoral intercondylar fractures.
