MedClips

 Foreign bodies in hand Common presentation at ER room May remain asymptomatic for prolonged periods of time Formation of foreign body granulomas, pyogenic granulomas, abscess Foreign bodies in hand Common presentation at ER room May remain asymptomatic for prolonged periods of time Formation of foreign body granulomas, pyogenic granulomas, abscess Localized pain  Foreign body granuloma presence of the foreign body changes the healing response protein adsorption, macrophages, multinucleated foreign body giant cells (macrophage fusion), fibroblasts, and angiogenesis Epidermoid cyst painless, benign, slow-growing soft tissue tumor occurs months to years after a traumatic event penetrating injury  → keratinizing epithelium into subcutaneous tissues  → produce an epithelial cell-lined cyst filled with keratin X-ray 38% of retained foreign bodies were overlooked  Unlike metal objects, glass and wood can be radiolucent Less than 15% wooden foreign bodies are detected ...

 Physeal arrest of the distal radius Physeal closure : 17 Y-O Neutral ulnar variance : 80% of wrist stress -> distal radius Positive ulnar variance : Distal ulnar stress↑ -> impaction to lunate, triquetrum, TFCC Etiology Physeal fracture  Vascular ischemia : compartment SD… etc Infection Management Conservative : Minimal growth remain (<2mm, Paley multiplier) Physeal bar resection : Demanding surgical procedure, attempt to young age Epiphysiodesis : Prevent angular deformity, arrest remaining growth, combined with radial or ulnar osteotomy Ulnar shortening osteotomy : Combined with distal ulnar epiphysiodesis, for ulnar impaction syndrome Radial osteotomy : Angular deformity correction, with or without acute radial lengthening Distraction osteogensis : Circular Ex-fix, for large LLD, fine tuning Surgical decision Ulnar variance restoration Radial inclination restoration Palmar tilt restoration Consideration of remaining forearm growth Mild angular deformityRemaining f...

 Indications for simultaneous bilateral TKR Cost effectiveness? 58% hospital charges in bilateral Lane et al., additional rehabilitation in 89% bilateral, 45% unilateral Infection rate, knee scores, radiographic criteria Controversy continues.. Blood loss, postop thrombocytopenia at 2nd day, DVT/PTE Indications for simultaneous bilateral TKR Fat embolism Dorr et al., 12% fat embolism syndrome in bilateral TKA Others, no difference in two groups Fluted intramedullary alignment rod + Enlarged entrance hole Comorbidities and physiologic age >70 yrs old, increased risk of cardiovascular, neurologic complications No increased risk, BMI>30 4 million hospital discharges over 14 yrs analysis Complication & mortality rate Bilateral TKA > unilateral or revision TKA Bone preparation Bone preparation Soft tissue balancing Coronal balancing Correction of Varus Deformity Correction of Valgus Deformity Sagittal balancing Correction of Flexion Contracture Correction of Recurvatum Corr...

 IntraarticTiming of surgery After recovery from the initial injury Resolution of inflammation Return of full motion Postop stiffness ular reconstruction Technical issues Graft selection Graft Placement Graft Tensioning Graft Fixation Graft selection Autologous hamstring Triple- or quadruple- stranded  Strength : semiT 75%, gracilis 49% of ACL Concern Tendon healing within the bone tunnel Lack of rigid bony fixation RCT  No significant difference in graft failure between BPTB and hamstring Graft selection Donor site morbidity Potential weakness of knee flexion ? No significat difference in hamstring torque at 2 years after surgery Regeneration of tendons Toshino et al. : significant weakness when flexion > 70’ Graft selection Allografts No donor site morbidity Shorter surgery time Smaller incisions Greater availability Risk of disease transmission From currently available literature, Graft source has minimal effect on the outcome Good results of autograft in young, act...

 Subacute osteomyelitis (Brodies abscess) Osseous infection > 2wks without acute Sx Less common than acute hematogenous osteomyelitis (AHO) Lack of systemic illness -> delayed diagnosis Lab may be normal or slightly elevated S. aureus is most common Location is more diverse than AHO Pathophysiology Host-pathogen relationship : bacterial virulence↓ & Host resistance↑ Inadequate treatment of AHO 40% of subacute OM : recent treatment of antibiotics for other infection (Roberts JM et al. 1982) Classification Treatment Biopsy to rule out malignancy Culture to confirm pathogen 6weeks course of oral antistaphylococcal antibiotics Primary regimen IV : Nafcillin, Oxacillin, Flucloxacillin, Cefazolin PO : Dicloxacillin, Cephalexin <5y-o : Kingella kingae. Should be covered : Clindamycin is recommended (McCarthy 2005) Complication Inadequate treatment -> can progress to chronic OM Rare report of growth disturbance Few report of LLD d/t growth stimulation

 Mirels’Classification Mirels H: Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop 249:256–264, 1989. Mirels’Classification : Nature of lesion Mirels’Classification : Nature of lesion Orthopedic Radiology: A Practical Approach, Greenspan, Adam; Lippincott, 2000 Diagnosis of Bone and Joint Disorders, Resnick, Donald, W. B. Saunders Mirels’Classification : Nature of lesion Score of 8 or higher  consider prophylactic internal fixation Guideline aids in decision making, but does not serve as an absolute criterion Each patient should be evaluated individually, keeping two generally accepted principles in mind.  First, prophylactic internal fixation of an impending fracture is technically easier than fixation of an actual pathologic fracture. Second, patient morbidity is decreased with prophylactic fixation compared with fixation after the fracture. Prophylactic intramedullary fixation(↓pain and prevent subsequen...

 Status of bone Classified based on location, infection, and etiology:  Epiphyseal, metaphyseal, or diaphyseal Septic or aseptic Hypertrophic, oligotrophic, or atrophic Pseudarthrosis Classification Classification Classification Classification Pseudarthrosis Properties of hypertrophic nonunion Pseudomembrane containing fluid like an actual synovial joint Sealed medullary canals  Variable radiographic appearance Bone scan reveals “cold cleft”  TX :  debridement of pseudoarthrosis opening of the medullary canal enhancement of stability (compression)  bone grafting Indications and Contraindications forNonoperative and Operative Treatment Indication for nonop. TX Acceptable alignment  Reasonable potential for healing Time anticipated for healing is associated with little morbidity Contraindication for nonop. TX  Progressive fracture malalignment Implant fail Persistent excessive motion at nonunion site Infection