surgical technique

Definition

Metaphysical

Extra-articular

Treatment options

IMN

Plate

Results

Jindal et al. Indian J Orthop 2020

- systematic review

- no different in malunion

- infection more common in plate

Patella Baja

Aetiology

Congenital

Acquired

- trauma

- post ACL reconstruction / TKR

- chronic quadriceps rupture

Issues

Decreases ROM

Associated with early OA of the PFJ

Diagnosis

Blackburne-Peel ratio at 30 degrees flexion

AO Classification

Types

1. Supracondylar

2. Unicondylar

3. Intracondylar

Xrays

Supracondylar / Extra-condylar

Indications

< 60 with good bone stock and preserved joint space

Reduction

Union rates increased with anatomical reduction

Options

- closed reduction

- open reduction / if closed reduction fails

Accept

- no varus

- < 15^o valgus

- < 10^o AP plane

Disectomy Technique for Posterolateral L4/5 disc 

Anatomy

L4/5 disc at level of facet joints

Interlaminar space is below disc

- have to take inferior aspect of superior lamina

Pedicle and transverse process at same level

Disc usually on one side

- hemilaminotomy

- no need to remove spinous process

- this preserves stability

Definition

Benign enlargement of the common digital branch

- usually 3rd webspace

Anatomy

Found at level of or just distal to MT heads

- deep to the deep transverse MT ligament

Epidemiology

Classically women between 40 and 60

Non Operative

Options

Metatarsalgia

- preMT dome

Claw toes

- wide deep toe box

Foot drop

- AFO

Insensate foot

- custom orthosis

Varus

- lateral heel wedge

- AFO (flexible)

- medial iron with lateral T strap

Operative v Nonoperative Literature

1.  Buckley etal JBJS Am 2002

Prospective multi-centred RCT

- 309 displaced intra-articular fractures

- operative v non operative management

- 2 year follow up

Findings

- used patient orientated functional outcomes

- overall VAS and SF36 not significantly different between 2 groups

Improved Operative Outcome if

- not workers compensation

- women

- < 29

Results 

90% fusion rates

Lose70% sagittal plane ROM

Disadvantages of Arthrodesis 

Non union rates up to 12%

Decreased gait speed

Poor mobility over uneven surfaces

Approach

Incision

Always use the most lateral scar

- blood supply comes from medial aspect

- want to avoid a large lateral flap of dubious quality

- cross transverse scars at 90^o

- minimum 7 cm skin bridge

Options

- can do trial / sham incision down to capsule