JAAOS article questions

• Similar functional outcomes at 2 years
• >80 were using more walking aids

• 3.5x increased risk death
• 2.7x increase of MI
• Increase in risk of pneumonia
• Increase risk transfusion

• Decreases complications
• Decreases hospital stays
• Decreases rehospitalization

Posterior circumflex artery ( 64%)

• Metaphyseal head extension <8mm
• Medial hinge disruption >2mm

However does not correlate with AVN

• ORIF IN <65 y.o. better constant scores
• ORIF more complications vs HA (AVN + cutout)

• 2 part Surgical neck
• Young age
• Concomittant humeral shaft
• Impending pathologic

• Functioning rotator cuff
• Anatomically healed tuberosities

Top humeral head 5.6 cm above from upper border of pec major

• Scapular notching
• Glenoid loosening
• INstability
• Infection

• RSA less complications
• ORIF better functional outcomes

• RSA less complications
• ORIF better functional outcomes

• Increased glenoid retroversion
• Glenoid hypoplasia
• Reverse hillsack
• Increased humeral head retroversion

Flexion Adduction IR

• Posterior labrum: increases concavity compression
• Posterior capsule: PIGHL most important in IR and flexion.
• Posterior glenoid bone loss?humeral head
• Rotator interval

If shoulder dislocates posterior à the rotator interval should be disrupted anteriorly à needs plication when stabilizing posterior

• Acute trauma
• Repetitive microtrauma
• Insidiuos onset: generalized ligamentous laxity
• Voluntary

• Jerk
• Kim
• Posterior stress
• Load and shift
• Sulcus

• POsterior bankart
• Enlargement of posterior capsule
• Kim lesion: incomplete avulsion of the posterior labrum

• Failed conservative
• instability from an acute traumatic etiology and identifiable soft-tissue and/or osseous pathology.

• Ilac crest or distal tibial allograft
• no difference in results

Suture anchor > greater return to play

• 90%
• 64%

• 3%
• 30%: same to younger
• Improved if <3 days: decrease hospital discharge + minimize complications

• If pre op symptoms: better recovery
• If nerve damaged pre op

• Unable to ORIF with good stabilit
• Presence of pre existence of arthritis, no union, malunion

• Young high demand: weight restriction 10lb
• Cognitive impairement
• Neuro injury
• Presence infection
• Poor soft issue

• Osteolysis
• Loosening
• Failure
• Infection
• Fracture

• yes, Canadian study:
• does not compromise elbow strength or motion and can decrease surgical time and complexity, as well as eliminate pain secondary to condylar nonunion

• Semi- constraint
• Sloppy hindge ofloads cement bone interface
• Non constrainted- requires perfect soft tissue balenceing but preserves bone stalk

• TEA beter time
• TEA better score at 6 months
• TEA better at all point

• Improved radiological outcomes
• Low complications
• Improved function
• Better clinical results vs CRPP and ex fix
• Lower risk displacement and tendon irritation

• Iliac crest auto graft
• allograft
• hydroxyapatite
• calcium biphosphate

NO

separation of the ilium superiorly from the ischiopubic segment inferiorly

• Female
• Rheumatoid
• Radiation therapy

• Hemisphereic cup with posterior column plating: setting of acute fracture
• Highly porous coated acetabular components: need 50% host bone contact to cup
• Cup cage
• Distraction method
• Custom triflange

HO is the formation of trabecular bone in soft tissues where bone does not usually occur.

X-rays => 4wks // Bone scan can show inc. uptake before 4wks

Normal Ca & PO4 levels throughout Dx process

Alk Phos inc. in early HO & plateau’s at 4wks

Brooker

1) Island of bone within the soft tissues about the hip

2) Bone spurs from pelvis or prox femur with > 1cm between bone opposing surfaces

3) Similar to Class 2 but < 1cm between ends of bone spurs

• 4) Ankyloses of the hip

• Iliofemoral > kocher langenbech > ilioinguinal
• Complex exposure:
• -double exposure
• -trochanteric osteotomy

Debridement of necrotic muscle tissue

• a) Male
• b) TBI or thoraco-abdominal trauma
• c) Sciatic nerve injury
• d) femoral head injury/ intra-articular debris
• e) Delay to Sx
• f) Ipsilateral femur #
• g) Prolonged mechanical ventilation

Higher with early

XRT 600-800cGy within 72hrs post-op: better if given within 72 hrs

• Better than pre op XRT
• Better than NSAIS's

**Literature indicates that NSAIDs are ineffective for HO prophylaxis after Acetab Sx**

- Traditionally, resection delayed until mass was “Mature” but could be active in bone scan up to 2yrs.

- The recommendation is to resect the HO if symptomatic (causing neurodeficit or significant ROM limitations).

- Anticipate significant blood loss, prepare nerve stimulators & doppler to aid in difficult locations. XRT or 2wk course of indomethacin post-op.

Increased if delayed acetabular fixation

begins at the proximal edge of the volar carpal ligament

extends to the fibrous arch of the hypothenar muscles.

borders are not constant but most notably the pisiform and the hamate

• Zone 1:
• -3 cm in length - volar carpal ligament palmary and the transverse carpal ligament dorsally
• -proximal to bifurcation of the ulnar nerve into its motor and sensory branches
• -both paresthesia and intrinsic muscle deficit.

Zone 2

• -After the ulnar nerve bifurcates
• -deep motor branch goes dorsal and radial around the hamate as it dives deep to the fibrous arch of the hypothenar muscles
• -deficits in motor function only

• Zone 3
• - superficial sensory branch of the ulnar nerve as it courses palmar to the fascia of the hypothenar muscles.

• ulnar artery thrombosis
• ulnar artery aneurysm

• - Ganglion cysts
• - hook of hamate fractures
• - traumatic adhesions
• - anomalous muscles

• ganglion cysts  - 90% of cause in zone1 and 2
• fractures
• thickened pisohamate ligament.

• Tinel test
• sensory threshold testing,
• interossei wasting,
• inability to cross fingers
• unable to abduct little finger ( Wartenberg sign)
• Ulnar claw deformity
• -secondary to lumbrical paralysis of the little and ring fingers
• -extensor tendons place MCPs in hyperextension
• -long flexors place the PIP and DIP in flexed position.

Froment sign:Attempted pinch between the thumb and the index finger may lead to compensatory thumb IP flexion

Jeanne sign: hyperextension of the thumb MCP > paralysis of the adductor pollicis muscle.

• ulnar tunnel
• cubital tunnel
• thoracic outlet
• cervical radiculopathy syndromes

Determine using EMG!!

removal of mass effect lesionsdecompression of all 3 zones

• antebrachial fascia,
• volar carpal ligament,
• hypothenar fibrous arch (overlying the deep motor branch)

Ganglion cysts

5 cm long and begins as the radial nerve courses past the radiocapitellar joint.

Roof:  brachioradialis muscle

Medially: biceps tendon and the brachialis

Lateral: ECRB and ECRL + brachioradialis muscle.

Distally ends at the fibrous arch of the proximal edge of the supinator muscle (arcade of Frohse)

proximal, lateral forearm or elbow pain that often worsens with rotational movements of the forearm

lateral forearm pressure over the supinator muscle, with the wrist in full supination should reproduce pain: Pronation of the wrist during this maneuver moves the radial nerve away from the thumb-directed pressure, should relieve the pain.

Pain with resisted, active extension of the wrist or the long finger.

Slight weakness of the extensors secondary to pain rather than motor nerve dysfunction.

• Arcade of froshe
• Leading edge of proximal ECRB
• Compressive fascia of distal supinator

compressive neuropathy of the median nerve at the level of the elbow

• supracondylar process
• residual osseous structure on distal humerus present in 1% of population
• ligament of Struthers
• travels from tip of supracondylar process to medial epicondyle
• not to be confused with arcade of Struthers which is a site of ulnar compression neuropathy in cubital tunnel syndrome
• bicipital aponeurosis (a.k.a. lacertus fibrosus)
• between ulnar and humeral heads of pronator teres
• FDS aponeurotic arch

compressive neuropathy of the AIN that results in motor or sensory deficits

motor deficits only

no cutaneous sensory changes

tendinous edge of deep head of pronator teres

FDS arcade

edge of lacertus fibrosus

accessory head of FPL (Gantzer's muscle)

accessory muscle from FDS to FDP

abberant muscles (FCRB, palmaris profundus)

thrombosed ulnar radial or ulnar artery

• AIN syndrome: inflammatory
• Pronator syndrome mechanical

AIN syndrom motor deficits only

tendinous edge of deep head of pronator teres

Palmar paresthesia may help surgeons distinguish carpal tunnel compression from compression at more proximal locations

Pronator syndrome: presence of sensory deficits rules out an isolated AIN lesion but supports a diagnosis of pronator syndrome

Lacertus fibrosus: resisted elbow flexion with the forearm in a supinated position.

pronator teres : resisted forearm pronation.

FDS arch : resisted finger flexion --  PIP of long fingure.

Carpal tunnel:  Tinel sign and a positive scratch collapse test may be observed in patients with proximal median neuropathy.

attritional rupture of the FPL secondary to a carpal osteophyte

1) Stabilizes DRUJ

2) Cushion for force distribution btw carpus & ulna

• 1) Articular disc
• 2) Volar & Dorsal DRU ligaments
• 3) Ulnocarpal ligaments
• 4) ECU sheath
• 5) Meniscus homolog

A) Lax in neutral rotation & tight in Max. pro & supination

• 1) Traumatic
• 2) Inflammatory
• 3) Congenital
• 4) Degenerative

• Ulnocarpal stress test
• PT grind test
• Kleinman shuck
• Shear test
• Derby relocation
• Ulnar fovea
• Piano key

For ulnar sided wrist pain


wrist Max Uln deviation, forearm Neut, elbow 90deg then axial load on wrist while sup/pron => Pain is +ve

For ulnar sided wrist pain


Simply grind the pisiform on the triquetrum

For ulnar sided wrist pain

Also simple, hold triquetrum & pisiform on one hand btw thumb & index while the other hand holds the lunate & move both hands in opposite directions.

For ulnar sided wrist pain

Same as Shuck test but stabilize radiolunate instead of only lunate

to assess UT ligament or foveal disruption => Pain replicated by pressing on interval btw ulnar styloid & FCU tendon btw the volar surface of ulnar head & pisiform.

for ulnar sided wrist pain

evaluates DRUJ inj => Pronate the forearm, ulna is dorsally prominent relative to radius => if minimal restraint to volar displacement of the ulna relative to radius => +ve test for instability. Recheck with forearm in Supination.

1) Standard X-rays => Perfect AP, Lat & oblique views (30 pro & 30 deg sup)

2) CT => To assess for nonunion, subtle joint subluxation

3) CT arthrogram => high sens & specificity for lig inj 4) Dynamic CT => Ideal for assessing DRUJ translation

MRI has largely replaced MR arthrogram for wrist pathology => due to high false +ve, pain related to inj, chemical synovitis 2ry to contrast. If suspecting non benigh tumor => MRI + gado.

MR arthorgram

Wrist arthroscopy

6x higher non op with older rehab protocols

Comparable Op vs non op with early functional rehab

• 0-2 wks: Initial immobilization + NWB
• 2-4 wks: CAM (control ankle motion) + 2 cm heel lift + Protected weight bearing + ROM to neutral
• 4-6 wks: WBAT
• 6-8 wks: remove heel lift + Dorsiflexion stretching + Propioception
• 8-12 wks: Wean off boot

• Reduces ankle stiffness
• Better health related QOL
• Faster return to work

*No effect on rerupture rates

• Lower time to return to work
• Higher plantar flexion strength

• Rerupture
• Ulcers: foot
• Heel pain
• DVT/PE

Avulsion from calc

7-8%

• Female
• Smoking
• Steroids

• NO increase complications
• Improved QOL at 6 weeks
• Decreased activity limitations at 6 weeks

No studies show superior vs control group

Dynamic CT in pro/sup

• TFCC tear
• Ligamentous injury

• IV drug users
• Person who exchanges sex for drugs or money
• Person who have had >3 partners since last HIV test

0.3%

• Deep injury
• Visible blood on device
• Needle that had been placed on artery or vein
• Terminal HIV illness
• Large gauge needle (<18)
• Emergency procedure

• Major complications increased
• Perioperative wound infection
• Increased length of stay

Chronically elevated TNF-A > interferes with bone metabolism

• CXR if hx of PCP incfection: Risk spontaneaous pneumo
• Regular blood including liver
• CD4 counts + viral load

• Viral load >10 000-30 000
• CD4 count <200

• DVT
• Being admitted to ICU for mechanical ventilation
• Spontaneous pneumo

• THA
• Spinal fusion
• ORIF fracture

Type IV: delayed type > T cell mediated

• Female
• Piercings
• History hand eczema
• Metal allergy in first degree relative
• History of smoking
• Post well functioning arthroplasty
• Post failed arthroplasty → even higher than well functioning arthro

Nickel (14%)

Aseptic lymphocytic vaculitis-associated lesions

5ppb: also may need joint aspiratons

Low: Well fixed, good track record + no symptoms = annual follow up

Moderate: Well fixed/positioned + some symptoms or recalled implant = follow up 3-6 months. Revise if progressing symptoms,imaging abnormalities or elevated ion levels

High risk: severe symptomatic, high ion levels (>10 ppb), malpositioned components = revision

Observation

Percutaneous drainage: Some studies show high rate of reoccurence - esp if drainiage > 50cc initally 

Open debridement and irrigation

• Serial aspiration
• Compression bandage
• Liposuction
• Sclerosing agents

• 2  2 cm incisions at proximal and distal end of the lesion
• Simultaneous cavity access through these portals
• Brushed and pulsed irrigation
• Debride necrotic tissue
• Placement of percutaneous drain
• Drain removed after 2 weeks or when drain <30 cc per 24 hrs

Fluid aspirate >50 cc if done percutaneously

• Talcum powder
• Doxycycline

a clinical condition characterized by activity-related pain in the distal pole of the patella or in the proximal patellar tendon

D)

• 1-     high body mass index
• 2-     a large abdominal circumference
• 3-     limb-length discrepancy
• 4-     flatfoot arch
• 5-     weak quadriceps
• 6-     low flexibility in quads and hamstrings

Answer: Tendinosis typically is in the posterior portion of the proximal end of the patellar tendon adjacent to the inferior patellar pole.

NO, progressive degeneration of the tendinous tissue, an inability of the tissue to repair itself, and the absence of inflammatory cells.

• 1-     Decline squat test: pain at distal pole patella at 30degress of flexion of knee on single leg squat
• 2-      Pain on palpation of distal pole pf patella

• Patellofemoral pain syndrome
• Fat pad syndrome
• Meniscal tears
• Cartilage lesions
• Referred pain

1-     Eccentric exercises – good data only one with good data

2-     Extracorporeal Shock Wave Therapy – still experimental

3-     Steroid injection – Not recommended

4-     PRP – non consistent evidence in lit

5-     Cell based therapy – experimental

6-     Hyaluronic Acid – no evidence

7-     Sclerosing Agents – experimental

Arthroscopic and Open - The goals of these techniques are tenotomy of the patellar tendon, excision of abnormal tissue, and induction of the repair process through stimulation of the inferior pole of the patella by drilling and marginal resection.

Similar results in Open and arthroscopic technique: faster return to sports in arthroscopic treatment

-       8.1%-25%

• -       more likely anterior column
• -       fall onto posterior lateral hip à drives into ant column/ quad plate à protusio with intact posterior columno   medial dome impaction --> poor outcomes-       

• If post column:-      
• More comminuted-       
• More marginal impaction-       
• Posterior wall, hip dislocation and medial dome impaction-       
• Poor outcomes with surgery

-       reduced the LOS

-       readmission rates

-       time to surgery

-       complication

• -       mortality rates
• -       hospital-acquired complications and improved outcomes in geri trauma

-       Therapy guided toe touch weight bearing for 6 weeks

-       Radiographs at 2,6,12

-       Often asymptomatic by 4-8 weeks

-       Column fractures with good bone coordiors

-       Excellent knowledge of technique and anatomy required

-       Conversion to THA similar to open fixation – ave 2.4 y

-       EBL much lower

Gull sign

superomedial dome impaction

-       10-37%

-       studies show signficnat patient hip score improvment for post traumatic OA from Acetabular fracture to THA

-       uncememted superior survival to cememtned

• -       age 40 years
• -       nonanatomic reduction
• -       hip dislocation
• -       acetabular roof or posterior wall involvement
• -       acetabular articular impaction
• -       femoral head involvement-       initial displacement more  than 20 mm

• -       Reconstruction of stable columns
• -       Enough stability to accept press fit component

Need for dual approach do worse

• -       cement the stem
• -       place press fit cup into a position that affords max stability
• -       cement in liner into optimal anteversion
• -       patients ambulating within 7 days on average

• -       ORIF and THA resulted in slightly less surgical time
• -       increased blood loss
• -       rate of coversion of ORIF to THA was 22% at 2 years
• -       mortaility same
• -       HARRIs hip scoresà higher in the ORIF
• -       SF-36 better in THA

• Male
• Caucasian
• Obesity
• Older
• age

L4-5

Achondroplastic and idiopathic

• Most commonly affects L3-L5
• Decrease in Canal/VB ratio
• Decrease in AP canal diameter to AP VB diameter ratio
• Decrease in the transverse canal diameter to transverse VB diameter ratioShort pedicle

• Disk-osteophyte complex
• Ligamentum flavum hypertrophy

Facet hypertrophy associated with osteophytes

• Loss of disk height leading to collapse in the foramen
• Osteophytes
• Disk protrusion
• Angulation (scoliosis)

Far lateral disk herniation

• Moderate < 100 mm2
• Severe < 75 mm2

A) Preganglionic nerve injuries (higher risk w/ subclavian Vs. axillary art. Inj) have limited healing potential, while postganglionic has greater nerve regenerative capability.

A) Motorcycle accidents 44% followed by MVC 35% ((Distraction injury))

A) Musculoskeletal & vascular structures are 1st injured while Brachial plexus is injured last.

• A) 10%. Important to R/O other causes of absent pulses =>
• 1) Hypovolemic shock
• 2) Peripheral vasoconstriction
• 3) Ipsilateral extremity injury.

• Asymmetric shoulderss
• NV exam
• Horner syndrome for pre ganglionic injury

Non rotated CXR

• Distraction clavicle #
• Scapular index: distance between spinous process and medial border of scapula (+ve 1.29)

Distance btw spinous process and medial border of scapula (>1cm uninjured side)

Need to performed 3-4 weeks post injury

Can help locate lesion

Stabilization after vascular repair to stabilize or progressive neurologic deficit.

    Otherwise, once pt. general condition stabilized

ST injuries without active arterial hemorrhage or limb threatening ischemia could be managed with observation alone.

- If vascular repair is ever needed then UE fasciotomies + stabilization of clavicle, SC or AC fixation should be considered.

- Historically, complete preganglionic injury was managed with immediate above-elbow amputation +/- shoulder arthrodesis.

- Recently, increased interest in nerve transfer or neurotization in pts whom avulsion of nerve from the muscle.

A) Restore elbow function, shoulder stability, hand grip & sensation.

A) - No later than 6 months if no neuro recovery - Shorter time to Sx may have improved functional outcomes.

10% (Maybe even more since pt. die without knowing if they have it)

- Of pts who survive evaluation & Dx => 52% have flail extremity & 21% early above elbow amputation.

Fusion of the carpus to the radius. Eliminates wrist Flex/Ext & Uln/Rad deviation but preserves forearm rotation.

Fusion rate is significantly higher (98% Vs. 82%) in plating & complication rates significantly lower (51% Vs. 79%)

• Rheumatoid Arthritis (Significant decrease in numbers with DMARDs)
• Post -traumatic arthritis
• Osteoarthritis
• SNAC & SLAC
• End stage Keinbock Dx
• Spastic wrist contracture
• Distal radius non-union/malunion
• Pseudoarthrosis of prev. Arthrodesis
• Failed PRC
• Failed SL reconstruction
• Preiser osteonecrosis
• Silicone synovitis
• Failed wrist arthroplasty

overall 29%

• Nonunion 4.4%
• Ulnocarpal impaction
• Carpal tunnel syndrome
• Extensor tenosynovitis
• Deep infection
• Implant-related problems (Persistent pain, prominent HW, # around implants)

• In pts with Rheumatoid Arthritis
• All pts were highly satisfied in both techniques BUT Fusion provided more reliable pain relief, lower rate of complications, less frequent need for revision than Arthroplasty.

Both procedures were extremely cost effective.

• In pts with post-traumatic Arthritis
• Both groups had similar DASH scores & comparable complication rates. However, Arthroplasty group had a significant better mean Patient-Rated Wrist Evaluation (PRWE) score.

• < 50yrs
• Manual laborers
• Hx of infection
• Use of Walking aids
• Lack of active wrist motion

Recent literature demonstrates high satisfaction rate  in long term F/U.

((Historically, surgeons recommended preservation of motion in one wrist when other is fused))

• Active infection
• Lack of adequate soft tissue envelope

((Poor bone stock in RA is not a contraindication anymore with the use of Locking plates))

Precontoured stainless-steel locking plates (Majority of cases)

Steinmann rods (2 to control rotation) => for pt. Who require MCP arthroplasty & if forearm dissection can’t be performed

1) 10-15 degrees of extension + Slight ulnar deviation ((Shown to have significantly better grip strength))

  2)  Neutral position ((Thought to have better pro/supination + balanced flex/extensor forces))

• Mucoid
• Serous
• Hemorrhagic

Key point: Facet cysts arise from the zygapophyseal joints of the lumbar spine.

• L4-L5 (68%),
• L3-L4 (14%), and
• L5-S1 (12%)

33% to 92% of LFCs were associated with spondylolisthesis

• NSAID's/supportive
• Percucaneous drainage: 80% success...CT guided is better than U/S guided
• Surgical decompression: 80% success

1.8%

• CSF leak (adherent to dura)
• Spondylolisthesis
• DVT
• Death

• Wound infection
• Increased LOS
• Increased blood loss
• Increased CSF leak

MRI GADO

• Mucoid
• Hemorragic

• Trauma
• Surgical positioning
• Overexertion
• Infection
• Vascular insult
• Snake or insect bites

adolescent boys at particular risk due to rapid growing muscle in inelastic fascia

• Begins 4hrs
• Permanent 8hrs

>40% in tibias

11% of all tibia fractures

• >14 yo
• Tibial tubercle avulsion

• Patient >50 kg
• Comminuted #
• Neuro deficit prior to tx

• open fracture
•      longer surgical times
•      IM nailing
•      Neurologic injury
•      Displaced supracondylar and displaced forearm: 33% chance of ACS

• Often don’t present with pain (50%)
•      60% have vascular changes on exam
•      36% have motor deficit·      poorer outcomes due to more rapid onset of ischemia

• High tibial osteotomites à advocate prophylactic anterior compartment fasciotomy
•      Prolonged dorsal lithotomy position

• anxiety
• agitation      
• analgesic requirement

seem to tolerate >30mmhg with no problem as long as pressure not within 30mmHG of MAP

• Maintain normotension
• remove circumferential dressings
• limb at heart height·    supplemental oxygen

Some evidence that children have more ability of spontaneous muscle recovery after myonecrosis

Adults – wound that can not be closed at initial surgery likely needs skin graft


     Kids à unlikely to need skin graft (12-21% of cases)

• UE worse than LE
• Not associated with fracture

D)

A: Fibrillin-1 (FBN1) gene

A: Skeletal findings are usually the first manifestation.

A: Aortic root dissection

• Aortic dissection
• MV prolapse
• Pulmonary artery enlargement
• Left ventricular enlargement

A: Beta blockers

A: Superolateral

• Pectus carinatum or excavatum
• Abnormally long fingers (arachnodactyly)
• Wrist sign (contralateral thumb overlaps the entire nail of the little finger when grasping the opposite wrist)
• Thumb sign (when the entire distal phalanx of the clenched thumb protrudes beyond the ulnar border of the hand)
• Scoliosis
• Acetabular protrusio
• Pes planus

Bracing, however less effective than in AIS. Usually in skeletally immature patients with 15-25 degrees curves

Surgery should be considered for curves > 45 degrees

• Dural tears
• Hardware failure
• More revision procedures due to implant failure or fractures

• Narrow pedicles
• Wide transverse process
• Vertebral scalloping

Definition: enlargement of the dural sac

Location: most common in the lumbosacral spine

Note: it is a highly specific finding of MFS and is present in more than ⅔ of patients with MFS

• Higher risk of aortic dissection because of hormonal and hemodynamic changes
• Avoid hypertension throughout pregnancy
• Beta blockers

• TMT joint
• Intermetararsal joint
• Proximal intermetatarsal joint

3 cuneiforms + corresponding metatarsals have trapezoidal shape

MIddle cuneiform and 2nd metatarsal act as a keytone > inherent stability

Most recessed

• Transverse intermetatarsal ligaments: secure bases of second to fifth MT
• Dorsal interosseous ligament: secure medial cuneiform to 2nd MT
• Plantar oblique ligament: insert onto bases of second and third MT
• Lisfranc ligament

Plantar: that's why there is often dorsal subluxation

• Tib ant
• Peroneus longus

Tib ant

• Medial column: Medial cuneiform and 1st metatarsal
• Middle columb: Middle and lateral cuneiform + 2nd and 3rd MT
• Lateral column: 4th + 5th MT + cuboid

• Lateral: shock absorber. Keep mobility when fixing injuries
• Middle is least mobile

• Direct: crush injury to dorsal aspect of foot
• Indirect: Axial and rotational force applied to plantar flexed/fixed foot

Echymosis plantar arch

• On AP: Medial border of 2nd MT with medial border of middle cuneiform
• On Oblique: Medial border of 4th MT with medial border of cuboid
• On Lateral: No dorsal subluxation of MT
• Fleck sign: avulsion # off base 2nd MT
• Widening >2mm btw 1st MT/Cuneiform and 2nd MT

• AP weight bearing of both feet on one cassette
• Pronation abduction stress xray

Plantar oblique

• Joint congruity
• Location of involvement
• Direction of instability

• Normal weight bearing x rays
• If high suspicion need to do EUA to rule out instability

• Medial: rigid fixation
• Lateral: Flexible temporary fixation

• Start from proximal to distal
• Continue from medial to lateral

2 INCISIONS

• Dorsal-medial:
• Btw 1st and 2nd rays
• Dorsalis pedis and Deep peroneal nerve identified and mobilized lateral
• Interval BTW EHL and EHB
• Visualize 1st TMT and medial aspect of 2nd TMT
• Protect branches of SPN in proximal part of incision

Dorsal Lateral

• Centered over 4th MT
• Visualize lateral 2nd MT + 3rd/4th TMT
• Common extensor tendons mobilized medially
• Muscle belly of EDB split in line with its fibers

Burr a hole in dorsal cortex of MT to allow screw to countersink

• Impaction of cuboid
• Leads to shortening of lateral column > need to restore

• NWB x 8 weeks
• Supportive shoe wear at 3 months with arch support

• Transarticular screw: very stable but violate joint
• Dorsal bridging plate: equivalent biomechanical to screw
• Tight rope: Cadaveric study show equivalent stability to screw

COmparable rates of complications and no difference in functional outcomes in small studies

Arthrodesis group had

• Improved functional outcome
• Higher return to pre injury levels
• Lower revision
• Less pain

• THIS IS THE QUOTED PAPER THATS SAYS ARTHRODESIS IS BETTER

Reduced mobility = loss of muscle mass and length (decreased sarcomeres) = loss of elasticity in connective tissue = loss of ROM

irreversible: 4 weeks

reversible: within 2 weeks if re-mobilise and muscles activated

• Passive Stretching: lit conflicting results
• Continuous Passive motion: no evidence in lit
• Splinting: recommend static progressive splinting
• Serial casting: TBI can be effective otherwise questionable
• Neuromuscular Electrical Stimulation: Bad results
• Botox: good short-term results in lit … l

Plating constructs must have mechanical characteristics that are neither too stiff nor too flexible to promote callus formation and avoid non union, malunion and implant failure

• Excessive soft tissue dissection à reduces biology
• Prolonged healing and porotic bone creation

316L stainless steel

•  Pure Titanium
• Titanium alloy

Described as the Younges modulus of elasticity

Ability to resist deformation (strain) under certain stress


It is the slope of the Stress/strain curve

Also known as endurance strength

Ability of material to resist failure during cyclic loading at stresses under the ultimate tensile strength

Stainless steel

Titanium: Can undergo repetitive high cycling at low stress as seen in ambulation

Steel can resist high stress but few cycles of it

Titanium can resist more cycles of low stress

Rectangular implant – exponential of thickness

Nail – exponential to radius

Reliefs – to preserve periosteal blood flow

Screw wholes

Sharp corners

<2%

2-10%

If more will lead to fibrous tissue

Not enough micro-motion and no callus

Eventual fatigue failure of implant

Bending of plate concentrates at fracture like a lever

creates more motion at far cortex than near cortex

Regular screw brings plate closer to the bone: better torsional strenght

Use of non locked screw at the end reduces stress at end of plate

Plate material

Plate thickness

Locking vs non locking

Screw density

 Plate length

Working length

Simple: 7-8 times lenght

Comminuted: 2-3 lenght

should not exceed 40-50% of available holes

Distance between two closest screws or screw clusters to the fracture

At least 2 wholes should be left open on either side of fracture unless zone of commination is substantial

Obesity

Open fracture

infection

Stainless steel plates

Short plate length

smoking

Titanium locking plates (LISS)

• 50% when performed under GA
• Due to the posterior horn of the medial meniscus acting as a secondary stabilizer

Pull of the IT band as it passess posterior to the axis of the knee

True

The Lachman test was the most sensitive in both awake (81%) and anesthetized (91%) patients

All tests have similar specificity in awake patients, the pivot shift test is the most specific (98%) in anesthetized patients

In one study, they found that in grade III MCL tears, the ACL was disrupted in 78% of the times

At 0 degrees, the posterior oblique ligament and posteromedial corner complex

At 30 degrees, the superficial MCL

MCL: the femoral side


LCL: the fibular side

At 0 degrees: LCL, PLC, and or associated cruciates

At 30 degrees: LCL only

Dial test

Posterolateral rotatory drawer

External rotation recurvatum

Standing apprehension test (Patient stands with both knees slightly flexed and internally rotates the torso away from the leg, if any feeling of instability or apprehension → +ve)

It tests the PLC

The examiner pulls on both big toes and hyperextension is then measured using a goniometer or heel to table distance is measured.

With the patient prone, both knees are flexed first to 30 , then to 90, with external rotation applied to the tibias at each position with the feet fully dorsiflexed

10 degrees difference At 30 degrees: PLC

10 degrees difference At 90 degrees: PLC + PCL

97%

Posterior sag sign: Supine, hips flexed 45 degrees, knees flexed 90 degrees. Loss of the normal anterior tibial step-off compared to the normal side

Posterior drawer test: in the same position the examiner pushes the proximal tibia posteriorly with the foot in neutral rotation to check for translation

Quadriceps active test: same position as in the PDT, patient is asked to contract their quads. If the tibia reduces then it’s positive

1) Intra-articular hip injuries (FAI & labral tears)

   2) Adductor & rectus abdominis muscles strain

   3) Osteitis pubis/Athletic pubalgia

• Adductor strains
• Osteitis pubis
• Athletic pubalgia
• FAI

A) - Adductor longus, magnus, brevis, gracilis, obturator externus & pectineus.

B) Adductor longus: 2 weeks off playing

A)  -    Groin pain or medial thigh pain => exacerbated w/ resisted adduction & passive stretching.

A painful overuse stress inj. of the pubic symphysis that can cause lower abdominal pain or groin pain 2ry to excessive strain & motion of the joint.

Injury to any of the muscles originating from pubic symphysis (Rectus abdominis “Elevates” Vs. Adductors “Depress”) => alters symphyseal biomechanics which could lead to cartilage degeneration.

A) Spring test: pain with pressure on pubic ram >>pubic rami #

• Cystic change
• sclerosis
• pubic symphisis widening

Unilateral or bil. Lower abdo pain that can radiate to perineum & prox adductors from repetitive pivoting & cutting (

Pain with resisted sit ups

Studies showed that in elite athletes with chronic Adductor strains w/out MRI findings of enthesopathy => Injections caused pain relief up to 1yr. Less improvement with MRI findings

) 1) Open repair with or without mesh reinforcement

    2) Laparoscopic repair with mesh

    3) Broad pelvic floor repair with possible adductor release/repair & neurectomy

70 degree: increased is worse

Assesment of volar rim displacement n DR #

A) By extending a line from the volar cortex of the intact radial shaft towards the carpus => should bisect the central axis of the capitate head

• Radial shortening < 5mm
• Radial inclination > 15 deg
• Radiocarpal intra-articular step-off < 2mm
• Sigmoid notch incongruity < 2mm
• Tilt between 15 deg dorsal & 20 deg volar

When unstable fracture fragments are too small of distal for adequate fixation w/ locking plates.

1) Highly comminuted fractures when volar locking plate or fragment specific implant is not feasible.

   2) Open fractures with moderate contamination

   3) Medically unstable pts who cannot undergo a lengthy procedure

Excessive distraction from Ex fix or bridge plate

A) No effect on clinical outcome

A) Supination 60 deg for 6wks (Munster cast) => Followed by removable orthosis & starting ROM exercises.

Ex-Fix should not be kept more than 6-8wks then transitioned to cast or orthosis.

Bridge plate can be kept for 3-4 months till fracture healing

0.024mm/year

Hip AP: Distance from superior aspect of cup to superior aspect of head compared to distance from inferior aspect of cup to inferior part of head

No radiolucent lines measuring > 1mm in any 2 zones on AP

Canadian study by beaule

RSA

Ceramic with sleeve adaptor

Glut max insertion into femur: repair at the end

No difference

Increase the forces at the trunnion and are thought to contribute to corrosion

2mm

ROughen up the backside of the poly (from a study) and the cup with a burr

• Acetabular malposition  ( outside 35-55 degree zone)
• Conventional poly
• Femoral head <28

• Male
• Low charlson comorbidity score
• Higher pre op function

Type 1

• Minor and contained cancellous bony defects
• Metal augments

Type 2

• 2A: One femoral condyle or plateau
• 2B: Both femoral condyle or plateau
• both treated with metal augments or structural allograft

Type 3

• Deficient metaphyseal segment, comprises major portion of the condyle
• Metal augments, cones, sleeves, oncology procedure

• Cement + screw
• Cone, sleeve or augments

intact collateral ligaments without varus-valgus instability because the host soft tissue provides coronal stability

Torsional stress at fixation interface

• Rebuild tibia platform
• Reestablish flexion gap
• Reconstituting extension gap

30 mm

Femoral stem

Clubfoot with arthrogryposis

Drop toe sign: big toe is plantarflexed in resting position with no active dorsiflexion

70 degrees for the affected side and 40 degrees for the unaffected side

The shoes are positioned at shoulder width

Most centers recommend somewhere between 3-5 years of age. Never before 3 years

Less dorsiflexion of the affected foot

Dynamic supination

In patients who experience a relapse at age >= 2.5 year. Full tendon transfer and not split

A combined cuboid-cuneiform osteotomy (opening wedge for the cuneiform, and a closing wedge for the cuboid)

Usually done at the age of 4-9 years (mainly to have an ossified medial cuneiform)

<5% require any release surgery after being treated with the posetti method

Unable to achieve 15 degrees of dorsiflexion

o   Reduces 10-20% which risk hypoxic injury/death

o   No – can increase to 18000cells/ul

o   Third trimester



o   80% of calcium required for fetal development is taken from mothers calcium deposits



o   Resolves within few weeks after delivery

o   Treat like regular ATLS

o   Mother life over fetal life at all times

o   Maternal/fetal blood mixingo   Prevention of aortocaval compression (past 20 weeks)

o   Development of RH D antibodies by mother to RH+ blood of fetus

o   Test mother for RH D

o   If negative give RhD immunogloblulin to mother after trauma within 72 hrs

o   aortocaval compression from fetus

o   Leads to decreased venous return and cardiac output

o   Sympt: Dizziness, pallor, tachy, sweating, hypotension

• o   15-30 deg incline
• o   Angle to left

• Uterine tenderness
• Abdominal pain
• Vaginal bleeding
• Sustained contractions
• Ruptured membranes
• Abnormal heart rate
• Serum fibrinogen  < 200

o   Cumulative radiation should not exceed 5rad during preg

3-15 weeks: teratogenic

5x regular patinet

if bmi >25 OR 62

Genta/tobramycin

• o   Fetus at largest risk
• o   GA is considered safe but try for local / regional if possible

yes at all standard doses

second trimester

• LMWH
• + compression stockings

diasthasis >4cm

Fetal HR <100

• Prolonged decelerations
• Recurrent late decelerations
• Fetus older than 26 weeks

34 weeks

Pelvic fractures

1) Ulnar => Dorsal sensory branch of the ulnar nerve (DSBUN) => Supplies Ulnar side of the wrist + 2nd-5th CMC joints

2) Median => AIN, Palmar cutaneous branch, thenar motor branch => Supplies carpal joints

3) Radial => PIN & radial sensory branch

4) Lat. ant brachial cut => 1st CMC joint & radial side of the wrist   5) Med. ant brachial cuy

Chronic wrist pain > 6 months refractory to non-surgical management

Must be skeletally mature (No upper age limit)

• Active infection
• cognitive impairment
• Poor patient compliance

Dorsal approach (Btw 4-5th compartments) => PIN, AIN, Superficial rad nerve & DSBUN

Volar approach (Henry)

Retrospective study looked at ketorolac post spinal fusionHigher nonunion with ketorolac

Meta-analysis of 5 retrospective studies:Higher nonunion with high dose ketorolac (>120mg/dL)But no detrimental effects of short-term use of NSAIDs at normal doses

NSAIDs have a dose dependent effect on spinal fusion

Yes!

• Improve pain control
• Reduce opioid consumption
• Facilitate rehab

Yes (level 1 evidence)COX-2 inhibitors or short term, low dose nonselective COX inhibitorsDoes not affect spinal fusion rates

They reduce neoronal excitability via inhibition of the alfa2-delta subunit of the Ca-gated channels on presynaptic axons

• Reduction opioid use
• Lower PCA use
• Improved functional outcomes up to 3 months

• Yes (Level 1)
• Reduced LOS
• Reduce post-operative pain and opioid use
• No difference in leg or back pain after 2 years
• Similar revision rate

• Good post op pain control
• 41% less PCA use
• Increased foley insertions

Femoral nerve stretch

Recent RCT showed no benefit over placebo

After 6 week course of non Sx management fails

Genetics

Yes - elite athletes  does add risk

Loss of disk hydration → disk space narrowing → tears → eventual anklysosis + facet degeneration

Changes in end plates that correlate with positively to presence of LBP

failed non op at least 6 months!

Contrast to disc herniation → 6 weeks

No - can lead to quicker degeneration

• Narcotic abuse
• Smoking
• Workers comp
• Number of of fusion levels

90%

not harmful but no difference in outcome

• Preoperative
• Preoperative hgb level to 50 higher than your transfusion threshold
• Iron, erythropoetin, autologous predonation

• Anesthetic
• Controlled hypotension
• Epidural blockade
• acute normovolemic hemodilution

• Pharmacologic
• Antifibrinolytic agents: TXA
• Desmopressin: not great evidence

• Surgical
• Hemostatic products
• Cell saver

• Post op
• Physiologic transfusion triggers

• Surgical tine
• >6 levels fused
• Neuromuscular scoli
• CObb angle >50
• Use of ponte osteotomies
• Low body weight

A) A, preoperative fibrinogen level may predict increased blood loss and transfusion needs in AIS

• Low albumin levels: <35g/L
• Total lymphocyte count (<1500)

C)  – main blood loss from decortication which is venous … therefore lowering BP during case from anesthesia is not as effective as in other ortho cases

• Tachycardia
• Hypotension
• Urine output <0.5
• Acidosis

• > 5mm vertical displacement on flamingo view
• > 10 mm diastasis on AP
• Acute symphysis rupture after birth

• Symphyseal arthrodesis: use bone graft from iliac crest
• Look for symptoms of posterior instability

• Single leg standing view or flamingo view
• Normal vertical displacement is < 5mm

4.4 mm

• <2mm translation
• <3 degrees rotation

Arcuate ligament: located inferiorly

20%

The difference between medial and lateral condylar heights in relation to the tibial baseplateIt measured coronal stability

Medial ⅓ of the tubercle

Every 1cm of joint elevation increases PF joint contact force by 60%

patient bears weight with a knee locked in extension because of either a weakened extensor mechanism or pain.

• load bearing
• shock absorption
• joint stability and congruity
• joint lubrication
• Proprioception

LLD: bc of physis

-  < 2cm => No intervention

 - 2-5 cm => Contralateral hemiepiphysiodesis

 - > 5cm => extendible prosthesis or 2ry limb lengthening

• Less risk infection
• Higher union
• Less fracture

• Endoprosthesis
• Osteoarticullar allograft

1) Decrease periprosthetic osteolysis

2) Preserve bone stock as less bone needs to be cut & reamed

• Invasive expandable implants
• Non-invasive expandable implants

10%

1) Less energy expenditure (When compared to AKA)

2) Avoids phantom pain

3) Decreases the need for further Sx for LLD, revision of loosening or #.

• Functional ankle joint
• Functioning sciatic and its branches

A) No functional difference on the basis of treatment type

A) Long term QOL after 17yrs were nearly the same

Lateral → more circular and mobile, medial → more firmly attached to the capsule and medial collateral ligament and is subject to greater forces ( increased tear rate)

• ProneFlex knee to 90
• Use 2 foot high table and place your knee on posterior theight
• Grind knee in ext rotation ((for medial) and int rotation ( for lateral)  in:

• Compression → miniscus pain
• Distraction → rotational ligament pain Neutral

• Active patala grind test
• Hold patella with webspace of thumb finger and ask to contract quads

Specific for patellar instability → + is strongly indicative of symptomatic instability

supine with the knee flexed to 90 and the tibia rotated internally. >>knee extended >>pain

+ test: patient reports pain as the tibial spine abuts the OCD lesion on the medial femoral condyle at approximately 30 short of full extension.

A) optimize the body’s regenerative capacity and the function of the diseased joint. An external fixator is used to mechanically unload the ankle to relieve pain, preserve ROM, and potentially delay or even partially reverse the effects of arthritis.

C)

20 degrees

- decrease in joint reactive forces (shear)

- an increase in protoeglycan synthesis

- recruitment of mesenchymal stems cells

- optimization of the mechanical environment

A) Can take up to 12-24 months

- complex regional pain syndrome

- inflammatory arthritides

- previous infection

- neuropathic joint

- older patients with low demand

- flat top talus

Closely timed repeat injury that can result in brain swelling and even death

Neurodegerative disease associated with head trauma Diagnosed post mortum on histology Deposition of tau protein

• GCS <15
• Deteriorating mental status
• Progressive worsening neuro signs
• Potential spine injury

• Prior concussions
• Loss of consciousness during injury
• Female
• ADHD
• Depression
• Migranes

• acute : physical and cognitive rest
• Return to activity after patient is asymptomatic
• Procedure through a graduated stepwise return
• Must be symptom free for 24hr period before any advance in steps
• Min time 1 week
• If symptoms occur - go back to step where no symptoms

• No activity
• Light aerobic exercise
• Sport specific exercise
• Non-contact training drills
• Full contact practice
• Return to play

• Yes when started earlier in life
• Have positive effect on morphology of vertebrae

• Better cortical bone
• Improves pull out strenght
• Decrease scoliosis progression in type 3

• VC 78%
• VC 41%

37%: basilar invagination or impression

Stringest predictor is predictor of OI

• Fractures while positioning and transferring the patient
• Airway difficulties due to large head, large tongue and short neck
• Poor pulmonary function due to chest wall deformities
• The use of succinylcholine should be avoided because fasciculations can cause fractures
• Blood loss: blood should be available, controlled hypotension, and TXA

6-10%

Continuous drainage >72hrs post op: Allows for early intervention

• DM: 5X risk infection
• RA: 2-3X risk infection
• Smoking: stop 6-8 weeks before TKA (2X rate)
• Obesity: 6X risk of infection
• Malnutrition

• Inflammation phase: Time of incision to 4-6 days post op >>Fibrin clot serves to attract cells and concentrate cytokines and growth factors
• Proliferative phase: day 4-14. Epitheliazation, angiogenesis and granulation tissue formation.
• Maturation phase: Day 8 to 1 year, collagen synthesis and organization

• 3% at 1 week
• 30% at 3 weeks
• 80% at 3 months
• Wound strength never back to normal because of les organized tissue

• Albumin <3.5 g/dL
• Lymphocyte count <1500cells/mm3
• Transferrin < 200mg/dl

Deep perforators from the medial side of knee

From patellar anastamoses of the following vessels

• Supreme geniculate artery
• Medial superior geniculate
• Lateral superior geniculate
• Anterior tibial recurrent
• Branch from profunda femoris

The most lateral since the blood supply is medial

Ideal > 7cm

If the apices have a U-shape instead of a V-shape

A) Gram-positive anaerobic bacillus that is ubiquitous in the environment, particularly in healthcare institutions.

Deteriorated physical status & use of more than 1 Abx were the strongest risk factors

Rate of C diff infection is 8 times greater in orthopaedic trauma than in elective arthroplasty.

• Age >65
• Comorbidities
• History of GI surgery
• Antibiotic exposure
• Medications
• Tube feeding

• ORTHO
• Surgery >24 hrs after admission
• Revision
• Increased LOS

A) 3 or more loose stools in 24hrs with no other explanation

Toxigenic culture

The one that is currently done is toxin immunoassay

MIld: Oral FLagyl TID x 14 days

Moderate: Oral vanco QiD x 14 days

Severe: Oral vanco  + IV flagyl

Recurrent: Oral vanco in tapered regimen

• Clinda
• Fluoroquinilone
• Vanco

In order of most common

• Ganglion cyst
• Fibromatosis
• Exostosis
• GCT tendon sheath
• Lipoma
• NOF
• Schwannoma
• Enchondroma

• Synovial sarcoma
• Liposarcoma
• Fibrosarcoma
• Osteosarcoma
• Rhabdomyosarcoma

• Rapid growth
• Fam hx
• SIze >5cm
• Deep fascial layer
• incresed vascularity

Hemangioma

NF

NF

• Pedunculated 
• sessile

• When the lesion causes pain, deformity,or growth disturbance
• Increases in size out of proportion to the child’s growth

Dysplasia epiphysealis hemimelica (exostosis)

Tarsal bones > distal femur > proximal tibia  

Involve ½ of the epiphysis (medial)

Synovial sarcoma

Osteosarcoma

Control local edema: promote local vasoconstriction (study in ankle trauma shown 74% effective)

Decrease pain: systematic review shows it improves pain in soft tissue trauma and short term pain reduction with acute back pain

Decrease muscular spasm

Tested in inflammatory conditions like CTS and RA: No difference is size of hand

2 studies show decrease in  delayed onset soreness

No: study showed decrease performance and accuracy after acute cryotherapy

Reduces muscle guarding because it increases muscle laxity and decreases viscosity of connective tissues

Increased ROM when combined with stretching vs stretching alone

RCT showed no difference btw hot and cold when pt also took NSAID

Raises soft tissue temperatures by transforming waves to mechanical energy in the soft tissues

Depth of penetration: depends on frequency used

• Increases pain threshold
• Reduces edema
• Reduces inflammatory infiltrates and exudates

• Electrical stimulation of tissue
• Electrical stimulation of muscle
• Electrical stimlation of nerves

Gate control theory: Increased activity of nociceptors in response to afferent input causes presynaptic inhibition. This diminishes sensation of pain

• Delivery of pulsed current
• Activate descending inhibitory pathway to reduce hyperalgesia

• Interferential current
• Same principle as TENS but current comes from different angle so its effect is maximized in the deeper tissues

Post operative pain and swelling in the context of meniscectomy, ACL recon and chondroplasty

Uses electrical current to deliver chemical or a drug to biologic tissue

Delivery of dexamethasone onto tissue or lidocaine

SHown effective in athletes treated for lateral epicondylitis but only in the short term

Ring finger

• All surgical
• Long rehab: 4 months

• Type 1: retracted to the hand
• Leads to contraction

Decreased excursion to terminal flexion of the repaired digit limits excursion in the other digits

Occus if >1-1.5cm

2 Suture achors placed at 45 deg distal to proximal with locking stich in tendon

MPJ extension, PIP flexsion and DIP extension

• A2 and A4 in climbers
• Only A4 in pitchers

If no bow stringing can manage non op

Grade 4 → Op: bowstringing and multiple pulley ruptures

wrist flexion, ulnar deviation, and supination against resistance

ECU subsheath

Short arm or long arm splint in wrist extension and pronation x 2-4 weeks

Direct repair of subsheeth  vs reconstruction with extensor retinaculum

No need for groove deepening

UCL (primary) → 2 components: proper and accessory

Dorsal capsule

Volar plate

Osseous congruity

Retraction  of ligament resting proximally and superficially to the adductor aponeurosis

• Valgus stess at 0 → aUCL
• Valgus stress at 30 deg → pUCL
• Laxity of > 35 deg oir 15 deg more than other side in both 0 and 30 of flexion = complete rupture (Grade 3)

• Any Grade 3 in high level athlete
• Grade 3 with ligament displaced >3mm in anyone
• Stener leison
• Bony avulsions → often rotated and lead to chronic instability

Superfical branch of radial nerve

Adductor aponeurosis

• Static rigid body
• Dynamic msk
• Inverse dynamic
• Forward dynamic
• Finite element
• Hybrid

• Static rigid body
• Dynamic MSK
• Inverse dynamic

Finite element model

A) - Inverse Dynamic

C)

class I: 30.0 to 34.9 kg/m2

class II: 35.0 to 39.9 kg/m2

class III: 40.0 kg/m2

A)

A) - Comorbidities: many require attention, ex. DM



- Nutrition: most obese patients are malnourished (albumin ,3.5 g/dL, transferrin < 200 mg/dL and total lymphocyte count <1,500/mm3)



- Weight loss (no study showed significant (loosing 5% of body weight) weight loss prior to - surgery affects outcomes)



- Bariatric surgery prior to TKA (good literature results to decrease complications and re-operation)

- Exposure – advocate standard medial parapatellar approach

- Alignment – low threshold for navigation

- Blood loss – no obvious evidence of increase in blood in obese patients

- Fixation – No literature proof of loosening but suggest stemmed implants



- Anesthesia concerns – ventilation, spinals, blocks etc.

A) Fattys are always fat … I m jigged