Medial Unicompartmental Gonarthrosis

Medial Unicompartmental Gonarthrosis

Conservative Options

– NSAIDS – activity modification – viscosupplementation
– analgesia with Tylenol – physiotherapy – functional knee bracing
– oral glucosamine sulfate – weight loss – local measures (heat/ice)
– cane

Surgical Options

– arthroscopic debridement
– high tibial osteotomy
– unicompartmental arthroplasty
– total knee arthroplasty

Cervical Syndromes

Cervical syndromes
Cervical Spondylosis – Cord Compression Syndromes

There are a number of myelopathic syndromes

1. Transverse Lesion Syndrome
– most common
– little upper extremity involvement
– posterior column, spinothalamic, corticospinal tracts are predominantly involved to lower extremities

2. Motor System Syndrome
– bears a strong resemblance to ALS
– corticospinal and anterior horn cell dysfunction
– patient may have no sensory complaints, but motor function may be severely affected

3. Central Cord
– upper extremity worse than lower
– hand function affected the most has a poor prognosis

4. Brown Sequard
– unilateral cord compression – ipsilateral motor, contralateral pain and temp loss
– good prognosis

– correlating canal size and degree of myelopathy is difficult; the most important good prognostic factor may be minimal involvement; other favorable factors include symptoms

Spinal Stenosis 2

Spinal stenosis2
8. Documented instability at the level on flex/ext views – >4mm translation, > 10 degrees of angulation.
Intraoperative Structural Alterations
– taking >50% of the facet – the motion segment is unstable and should be fused.
– taking the disc out – aggressive discectomy renders the anterior column unstable and should be fused

The addition of instrumentation – also a controversial thing!

– Consider adding instrumentation when: 1. Correcting deformity. 2. Fusing more than one motion segment. 3. Treating recurrent stenosis and iatrogenic spondylolisthesis. 4. Documented instability preoperatively.
– the addition of pedicle screws to a single level degenerative spondy has been shown (Fishgrund) to improve fusion rates, but this had no effect on patient outcome.

Hawkins – Bankart 1

Surgical Technique

Bankart Repair – Dr. Hawkins

Positioning: Supine, 45o beach chair with head in Mayo headrest. Tip the legs up 20o, then tip the back up 25o to get 45o. The arm should be resting on the armrest. Head in the middle.

Prepping and Draping:

Shave the area. 10×10 steri-drape across the neck. Mark off the acromion and AC joint. The incision is made transversely in line with the fibers, about 1 cm medial to the lateral border of the acromion, and is about 10-12 cm long.


Anterior deltopectoral. The skin incision is vertical. Identify the top of the axillary fold with the shoulder adducted. Draw the incision vertically up from there. Then abduct the arm and carry the incision down 2 cm along the axillary fold.

Blade through the skin, then cautery to get through the epidermis to the subcutaneous fat. Use the mets once through the fat to identify the cephalic vein. Then de-roof the vein, and bluntly dissect between the deltoid and pectoralis muscles using your fingers. Crossing the deltopectoral interval superiorly and deeply is the deltoid branch of the thoracoacromial artery. This may bleed, but he does not generally go after it prophylactically – rather, he tries to mobilize it superiorly and out of the way. This should bring you down onto the conjoint tendon and the coracoid process. Use your finger to get above the coracoid process and clear the fascia our from above this. Then insert the coracoid retractor and use your mets to identify the very lateral border of the conjoint muscle/tendon complex. There is a well defined fascia here, so you need to get through this with the mets. Don’t be fooled into dissecting along the lateral border of the tendon, because you will denervate all of the muscle laterally. Gently mobilize the conjoint complex medially to identify the subscap tendon.

He uses a variety of incisions through the subscap tendon. Make a vertical incision about 1.5 cm medial to the insertion and gently cauterize down, careful not to go too far down and nick the anterior circumflex humeral vessel which lies at the inferior border. He sometimes hockey-sticks the incision medially. The trick to the cautery dissection is to watch for the crossing fibers – these are subscap tendon. When they disappear, then you are deep enough and are getting into the capsule. A trick is to go inferiorly into the muscle fibers of the subscap tendon, bluntly dissecting through them to ge to the correct plane of the capsule, then extend superiorly where the tendon and capsule are a bit more adherent and harder to separate. Superiorly, things get a bit tricky in that you need to continue to leave an adequate cuff of tendinous insertion to suture back to. A cobb may be helpful in sweeping the subscap tendon off the capsule, and similarly, a 15 blade can be used to develop the plane between the two once identified. Tag the superior border of the medial subscap tendon flap.

Make the capsular incision vertically starting about 7-10 mm medial to the subscap insicion and expose the joint. Inferiorly, turn the blade upwards and cut away from the axillary nerve. Again, superiorly make sure there is some capsule to suture back to laterally. Insert the Fukuda humeral head retractor and expose the glenoid. Look for the Bankart lesion anteriorly. Undermine the capsule off the anterior glenoid – don’t be fooled by the capsule and labrum that have pulled off and have adhered down to the anterior glenoid. They will be adherent in an incompetent fashion, and need to be dissected off the glenoid neck. Use the cobb to peel the capsule back off the bony glenoid neck, then insert the forked retractor in to retract the capsule back and expose the anterior glenoid. Roughen up with glenoid with an osteotome and mallet. Then identify where the suture holes are going to go. Use the single tap from within the articular surface to start the hole, and connect it up with the tap on the bony side of the glenoid. There is the clamp device to

MCQs – Upper Extremity/Elbow 3

MCQs-UE/elbow 3
Mason III fracture that is clearly un-reconstructable. In a Mason II fracture that you cannot fix, well, you might as well take that out too, as long as the rest of the elbow were stable and a longitudinal injury did not exists. Do not do partial excisions.

– for patients who come back long-term after having a radial head fracture that has not done very well, late excision has been reported to decrease pain and increase function in 70-80% of cases.

– for ununited lateral condyle fracture – watch out for progressive cubitus valgus and tardy ulnar nerve symptoms

– indications for fixing a medial epicondyle fracture: significant displacement (8-10 mm), valgus instability, ulnar nerve symptoms, incarceration into the joint. Remember to transpose the nerve.

– the best way to prevent proximal migration after Essex Lopresti injury is to fix the radial head. There are no other good solutions. The IO membrane and ligament DOES NOT HEAL.



– most common benign bone tumor arising in 2nd decade
– usu distal femur, proximal tibia & proximal humerus – disordered enchondral bone growth arising from metaphyseal surface of the bone adjacent to the physis
– may be sessile or pedunculated & grow away from the physis
– risk of malignant transformation to chondrosarcoma

Non Ossifying Fibroma (NOF)

Nonossifiying Fibroma (NOF)

– metaphyseal fibrous lesion of long bones (esp around knee) in children
– advanced form of fibrous cortical defect because no longer confined to cortex but extend into medullary canal
– usu ossify by 3rd decade

Signs & Symptoms:
– painful lesion
– pathological #

– clearly demarcated, eccentric, multilocular expansile lesions with scalloped, sclerotic margins
– bilateral or multiple lesions common
– cortex may be attenuated in areas adjacent to lesion

– spindle cells arranged in storiform pattern
– whorls of connective tissue interspersed with multinucleated giant cells & lipid-laden macrophages (foam cells)

– self-limited lesions – observation
– large lesions that encompass > 50% bone diameter may require curettage & bone grafting (impending pathologic #)

Reamed And Nonreamed Intramedullary Nailing On Fracture Healing

Reamed and Nonreamed Intramedullary Nailing on Fracture Healing

Reference: Chapman M.W., CORR, 355S pg S230-280, 1998

Main Message

– Intramedullary nailing has mechanical and biologic effects on fracture healing. The mechanical effects are known well documented; the biologic effects are less well understood (as are the implications of these on fracture healing). The molecular biologic effects have not been studied.

Points of Interest

Mechanics – influenced by nail geometry and stiffness
– geometry includes longitudinal shape, transverse diameter, cross sectional shape, slot
– stiffness influenced by material properties
– most are made of 316L stainless steel or titanium
– the modulus of elasticity of titanium is half that of stainless steel, but the ultimate strength is about 1.6 times that of stainless steel
– cross sectional area is important – moment of inertia increases by the FOURTH power of the radius, so as the diameter increases, the moment of inertia increases very quickly
– the main mechanical advantage of reaming is that a larger diameter nail can be inserted, which will be stronger, and will have a longer contact area through the isthmus


Pulmonary Effects of Reaming
– European studies showed a large difference in pulmonary problems with reaming; these results have not been reproduced in North American studies which have showed no difference in both animal models (Schemitsch – canine model) or clinically (Bosse – retrospective study of 453 patients, Chapman – prospective study of 82 patients).

Bone Vascularization Effects of Reaming
– cortex in the mid-diaphysis receives the inner 2/3 from endosteal vessels, the outer 10-30% from the periosteum
– the larger you ream, the more the total blood flow and cortical blood flow is reduced acutely.
– a strong hyperemic reaction is induced by reaming however.
– nails that tightly fit the inner cortex interfere more with revascularization
– muscle coverage is important for increasing bone perfusion if there has been soft tissue loss (open fracture)
– both reamed and unreamed nails create a zone of avascularity within the inner part of the cortical bone. This avascular zone of the cortical bone is smaller in unreamed nails acutely and at 6 weeks, but the difference decreases in time. The differences seem to be pretty small – 51% vs 62%, 40% vs 51%.

– Interesting review of the topic.

Calcaneal 1

Calcaneal 1
Calcaneal Fractures

Reference: Heckmann, James, in Rockwood and Green, 1996, Chapter 32

Main Message

These are devastating injuries. The jury is out with regards to the treatment. Probably, there are some that are better fixed, particularly by those who are good at them, and some that are better left alone. One hopes that Buckley’s study will delineate some of that…

Points of Interest


Plantar Surface – medial and lateral processes – for attachment of the plantar fascia and intrinsic foot muscles.
Dorsal Surface – posterior, middle, anterior facets
– Posterior facet – convex; makes up most of the subtalar joint
– Middle facet – concave; situated on the sustentaculum tali
– Anterior facet – concave; confluent with the middle facet
The calcaneal groove and interosseous ligament lies between the middle and posterior facets.

Bohler’s angle: the complement of the angle formed by a line drawn from the highest point of the anterior process to the highest part of the posterior process, and a line drawn from this point to the highest part of the tuberosity.

Most fractures are intra-articular – caused by axial loading. But there are many that are caused by twisting injuries – these are usually extra-articular.


– AP and lateral views are good
– Axial view of the calcaneus shows the width
– Broden’s view (a medial oblique view) – internally rotate the foot 45o, then shoot at 40, 30, 20, 10 degrees cephalad to get the right AP projection of the posterior facet
– Lateral oblique view – externally rotate the foot 60o and shoot 10o cephalad to get a good lateral of the posterior facet.

Extra-Articular Fractures

Anterior Process
Medial Process
Sustentaculum Tali

Anterior Process
– either avulsion fracture of the anterior process by the “bifurcate ligament” – a ligament the connects the anterior process to the navicular and cuneiform; or a compression fracture (more unusual)
– the pain is noted anterior and inferior to the anterior talofibular ligament, which makes it distinguishable from ankle sprains
– usually treated with cast immobilization; if large and unreduced, you can fix them. If they don’t heal, they may not be symptomatic. If they are, you can excise them with good results.

– avulsion of the Achilles tendon
– if minimally displaced, cast in slight equinus, 6 weeks
– if displaced, ORIF with tension band or screw, then cast in slight equinus

Medial Process
– serves as the origin of the abductor hallucis and the medial portion of FDB and plantar fascia
– avulsion of the plantar fascia
– treat with walking cast with molding to push the medial process laterally.

Sustentaculum Tali
– a Sanders IIC fracture
– pain is often accentuated by passively extending the great toe (pulls up on FHL)
– axial x-rays and CT are critical
– cast if nondisplaced. If more than 2 mm displaced, need to fix.

Body Fractures
– these spare the subtalar joint
– Bohler’s angle may be decreased, but with congruity of the subtalar joint
– generally speaking, require no treatment at all
– the indications to treat these are 1. If Bohler’s angle is significantly reduced (by 10o or more) because of the loss of mechanical advantage of the tendo-achilles. 2. If the heel has been significantly widened (will lead to difficult shoe wear and ulceration)
– If Bohler’s angle is reduced, you can put a Steinman pin transversely through the tuberosity, pull down on it, then put them into a cast, incorporating the pin.

Intra-Articular Fractures

Primary Fracture Line – runs obliquely from plantarmedial to dorsolateral, creating an anteromedial (sustentacular) fragment and a posterolateral (tuberosity) fragment. The sustentacular fragment is rarely comminuted, being attached to the talus by the strong deltoid and interosseous talocalcaneal ligaments. The tuberosity fragment is the one that gets shmucked.
– This primary fracture line is created in this fashion because the talus sits

Fractures And Dislocations Of The Foot 2

Fractures and dislocations of the foot 2
base of the second metatarsal. Note that there lacks such strong reinforcement between the first and second metatarsal bases, making this an area of instability.
– the key radiographic landmarks are: congruity from the medial border of the 2nd metatarsal and the medial border of the middle cuneiform; and congruity from the medial border of the 4th metatarsal and the medial border of the cuboid.

Classification (Quenu, Kuss)
Homolateral – all five metatarsals going in one direction
Isolated – one or two metatarsals
Divergent – usually between the first and second metatarsals

– needs careful clinical examination: these dislocations may reduce and look okay on xray, so you may overlook the severity of the injury
– look for pain on passive supination/pronation of the foot.
– on xray, fractures of the navicular, cuboid, cuneiforms, or of the metatarsal bases (particularly the second metatarsal) should make your suspicion increase.

– some authors have recommended cast treatment if the joint is reduced. Others suggest that the reduction can be lost when the swelling subsides and recommend fixing them
– it would appear that the most reliable way to treat these is to fix them; certainly, any displacement warrants reduction and stabilization
– Myerson’s guidelines – ORIF if >2mm displacement or a talometatarsal angle of > 15o.
– ORIF can be done through a dorsal longitudinal incision over the 1st/2nd interspace – this gives access to the 2nd metatarsal head which is usually the tough one to get reduced. Be aware that an entrapped anterior tibial tendon can block the reduction of the 2nd metatarsal.
– Fixation either with stout K-wires (0.062) or interfrag screw