JAAOS Sep2016 Flashcards
3 Goals of surgical treatment DDH hip
Obtaining a stable concentric reduction
Limiting risk of osteonecrosis
Limiting need for secondary procedures
OUTCOMES OF SURGICAL MANAGEMENT DDH Largely predicated on what 3 domains
Functional-McKay Criteria
Development of Osteonecrosis
Radiographic assessment-Severin Classificaiton
WHAT ARE 5 FACTORS ASSOCIATED WITH SUCCESSFUL CLOSED REDUCTION in DDH?
-use of preoperative traction
- fluoroscopic assessment of reduction
(arthrogram showing less than 5-6mm of medial dye pool or less than 16% of the size
of the femoral head)
- adductor tenotomy
- postoperative radiographic confirmation of reduction
- procedure timing
WHAT IS THE SAFE ZONE in DDH?
90-100 deg of flexion and <55 deg abduction
WHAT ARE 3 RISK FACTORS FOR OSTEONECROSIS following medial open reduction in DDH
younger age at time of procedure (<12 months)
need for further surgery
postoperative hip abduction angle >60deg
What are Indications for distal femoral traction pin (5)
Pelvic fracture with displaced hemipelvis (ie vertical shear injuries)
acetabular fracture with subluxation, incarcerated fragment, medicalization of femoral head
proximal 1/3 femur fracture
pediatric femur fractures
any condition that precludes a proximal tibia pin (stemmed TKA, unstable ligamentous knee
injury, comminuted tibial plateau fracture)
Contraindications to distal femoral traction (fracture patterns/characteristics)
undisplaced acetabular fractures that are stable
acetabular fractures thru the weight bearing dome as they are often irreducible and traction has
limited utility
Where should the distal femoral pin placement
medial to lateral >0.7cm proximal to the adductor tubercle near the metaphyseal flare
(basically at the top of the patella)
- avoid intraarticular placement
- can place eccentrically to allow for rodding of the femur with the pin in place
Indications and contraindications to prox tibia pin
Distal 2/3 distal femoral shaft fractures
Contraindications:
- ligamentous knee injuries
- tibial plateau fractures
proximal tibia pin dangers (3) and optimal placement?
dangers - physis, peroneal nerve, anterior tibial artery
- optimal placement is 2.5cm posterior and 2.5 cm distal to the tibial tubercle
Calcaneal pin use and position?
used to temporize tibial shaft fractures
o 2cm distal and 2cm posterior from the medial malleoli
o 3.1 cm radius of from the post-inf calcaneus
Inmates have what disadvantages compared to general population
- lower socioeconomic status
- are/were unemployed
- less educated
- less access to healthcare
- accumulated untreated injuries before incarceration
What are some health issues facing inmates (4)
1) SUBSTANCE ABUSE
a. 67% reg use drugs
b. 38-74% smoke
2) MENTAL ILLNESS
a. 33-50% have a psych diagnosis
b. 25% have substance abuse disorder PLUS mental illness
3) INFECTIOUS DISEASES
a. HIV 1.3%
b. HBV 2.7%
c. HCV 9.8%
i. Compared with 0.4% HIV and combined HBV/HCV 1.1% in the gen
population.
d. MRSA – twice the general population
4) INJURIES
a. 32% report an injury while incarcerated
Name 6 factors affecting delivery of health care to inmates
- safety and security often take precedence over health care needs
- inmate transfers
- non-compliance, lack of cooperation of patients
- delay and interruption of care
- referral process burdened by admin and security protocols
- lack of services i.e rehab is non-existent
MANAGEMENT OF SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE
Goals of tx: (5)
enhance sitting balance enhance posture improve lung and GI function reduce pain and deformity avoid complication -increased rates of complication and revision surgery in this population
SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE
Etiology (4)
Parkinsons
- Cerebral palsy
- MS
- Myopathies (endocrine, paraneo etc)
NEUROMUSCULAR SYSTEM CHANGES WITH AGING (8)
proprioceptive disintegration
- dystonia
- rigiditiy
- polypharmacy
- soft tissue changes
- degenerative spinal changes
- sarcopenia
- decreasing cognitive function
SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE
Classification (4)
ANTEROCOLLIS (DROPPED HEAD SYNDROME)
a. Minimum of 45 deg of cervical flexion which may be partially overcome passively or
actively
PISA SYNDROME (PLEUROTHOTONUS)
a. Defined by >10 deg of lateral thoracic flexion that can be corrected passively or by
supine positioning
SCOLIOSIS
CAMPTOCORMIA (bent spine syndrome)
a. Defined as >45 deg of thoracolumbar flexion with almost complete resolution in the
supine position
SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE
Non-surgical Options (6)
- optimize medical management (levodopa can worsen camptocormia and pisa syndrome)
- PT
- Bracing with thoracolumbar anterior distraction
- Botox iliopsoas injection
- Lidocaing external oblique injection
- Deep Brain Stimulation
SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE Surgical options (2) and considerations (3)
-NOT offered unless there is radiculopathy or myelopathy
- SHORT fusion constructs and decompressions are recommended in pts who have low
motivation to walk
- LONG contructs and major deformity correction are recommended in patients who are highly
motivated to walk AND have minimal major comorbidities.
- Patients are often osteoporotic so this is a major consideration
- Rehab is also a problem due to poor ambulation
SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE
Complications with surgery and %
- medical complication rate of 16.7 % in PD patients (delirium, PE, ACS, Ileus, UTI etc)
- delirium – rates as high as 66%. Associated with inc LOS and dec outcome scores at 6/12
- PJK – rates of 4-16% reported in elderly patients
- Instrumentation failure – as high as 29%
- Revision – reported rates from 50-86%
SPINAL DEFORMITY IN ADULT PATIENTS WITH NM DISEASE
Surgery, correction goals:
i. Pelvic tilt <25 deg
ii. C7-S1 SVA <5cm
iii. PI – LL <10 deg
ICL – UPDATE IN PEDIATRIC MSK INFECTIONS
etiology: primary and secondary
Primary - due to hematogenous spread or direct innoculation
Secondary - due to spread of OM
ICL – UPDATE IN PEDIATRIC MSK INFECTIONS
most common organism?
S Aureus is the dominant causative agent
ICL – UPDATE IN PEDIATRIC MSK INFECTIONS
Other organisms to consider in puncture wounds, exotic countries, sickle cell
Pseudomonas in puncture wounds
TB - children are more likely to have extrapulmonary involvment
Salmonella in sickle cell
ICL – UPDATE IN PEDIATRIC MSK INFECTIONS
consider in refractory infections?
MRSA
ICL – UPDATE IN PEDIATRIC MSK INFECTIONS
Labs? (6)
LABORATORY MARKERS
- WCC
- CRP (CRP>200 95% sensitivity)
- ESR (>20 94% sensitivity)
- Plasma procalcitonin
- Blood cultures
- Joint aspirate/bone aspirate (>100K, 90% PMN) highly suggestive
ICL – UPDATE IN PEDIATRIC MSK INFECTIONS
Periosteal reaction
Osteolysis
Joint space widening
Soft tissue changes
ICL – UPDATE IN PEDIATRIC MSK INFECTIONS
Differential of limb pain and fever, not infectious (3)
- TRANSIENT SYNOVITIS
- JIA
- NEOPLASM
Kocher criteria is what?
Predictor of pediatric septic joint KOCHER CRITERIA i. Fever ii. NWB iii. ESR >40 iv. WBC >12 1. 0/4 - 0% 2. 1/4 - 3% 3. 2/4 - 40% 4. 3/4 - 93% 5. 4/4 - 99% ii. CRP >20 mg/L (Caird et al) - strong independent predictor iii. MOST IMPORTANT ARE ELEVATED CRP and WB
JIA, what is it?
Age, presents how, where, dx criteria?
Age of onset most commonly 7-12
b. Common triad FEVER, RASH, JOINT INVOLVEMENT
c. Often Migratory and polyarticular
d. Knee most common (in 2/3rds) followed by ankle
e. DIAGNOSTIC CRITERIA
i. Fever for 2 weeks
ii. Joint effusion for 6 weeks
a. Joint aspirate
i. 25,000 - 100,000 wcc with >75%PMNs
ii. Intermediate glucose level
Neoplastic conditions mimicking infection in paedeatrics
Leukemia
b. Osteosarc
c. Ewings
d. Chondroblastoma
e. Primary Lymphoma of bone
f. Metastatic neuroblastoma
ICL – UPDATE IN PEDIATRIC MSK INFECTIONS
Indications for surgery? (Septic joint and in OM)
Septic arthritis o I+D plus abx OM o Generally the mainstay of tx is antibiotics o Surgical indications include Subperiosteal abcess Evidence of bone necrosis Direct invasion of the growth plate Contiguous spread to joint Failure of medical management
ICL – UPDATE IN PEDIATRIC MSK INFECTIONS Complications general(6) OM (4)
Persistent bacteremia DVT Septic PE Pathological fracture Growth arrest LLD/Angular deformity OM long term complications: o Osteonecrosis o Chronic osteomyelitis o Gait abnormalitiies o Premature arthritis
GREEN RESEARCH ARTICLE
THE USE OF MRI IN EVALUATING KNEE PAIN IN PATIENTS AGED 40 YRS AND OLDER
Inclusion Criteria:
- patients over 40 yrs old
- referred for evaluation of knee pain in 2012
What were the results?
- pre-referral use of MRI in 22%
- Plain xrays ordered pre-MRI in 58%, of these 13% had WB views
- 17% had >50%loss of joint space
- 48% of MRIs did NOT contribute to treatment recommendations
- in patients with>50% joint space narrowing and MRI was considered unnecessary in 95%
PREVALENCE OF OBESITY IN PATIENTS WITH LCP
Neal et al
Problem: There is no recent evidence on the prevalence of obesity in patients with LCP
Study Type: Retrospective Cohort study, 150 patients
Inclusion Criteria:
- Any patient presented with LCP over a 5 yr period
Results? (5)
-2% underweight
- 50% normal weight
- 16% overweight
- 32% obese (compared with 18% obesity rate for normal population)
- obesity was associated with later walderstrom stage at presentation, Lower median household
income and greater use of government funded health insurance
- Obese patients had a 2.8X lower likelihood of receiving a bony procedure
