Sport & Reconstruction

Sholahuddin Rhatomy, MD
SPORT &
RECONSTRUCTION
Sholahuddin Rhatomy,
Rhatomy, MD
1
ORTHOPAEDI UI
1. SHOULDER…3
2. Biomekanika shoulder…3
3. Shoulder dislocation …7
4. Shoulder Instability…13
5. Rotator cuff disease…22
6. Calcific Tendinitis…31
7. Frozen Shoulder …32
8. HIP…36
9. Anatomy…36
10. Femoral& pelvic osteotomy…40
11. Hip Arthrodesis…44
12. Osteonecrosis…47
13. THR…57
14. Hip Dislocation…93
15. KNEE..100
16. Anatomy…100
17. Knee ligament injury …108
18. Meniscal Injury…114
19. Osteochondritis dissecan…123
20. Spontaneus Osteonecrosis of knee..125
21. Spontaneus Osteonecrosis of femoral condyle..127
22. OA knee…128
23. TKR…134
24. Knee Osteotomy …158
25. Knee Arthodesis…160
26. Knee arthroscopy…161
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ORTHOPAEDI UI
Shoulder
Biomechanics
KINEMATICS
SCAPULO-HUMERAL RHYTHM
• ST joint
• Medial border of scapula articulates with posterior aspect of 2nd to 7th ribs
• Angled at 30 towards anterior & has 3 upwards tilt
o o
• 2 major ST bursae
• Scapula must upwardly rotate to allow overhead activity
• Scapulo-humeral rhythm
• 1st 45 of humeral abduction accompanied by movement of scapula
o
• For every 15 of abduction, there is 10 at gleno-humeral joint & 5 at scapulo-thoracic

o o o
joint
• Ratio of glenohumeral to scapulothoracic motion during abduction is 2:1
• Loss of smooth motion (normal scapulo-humeral rhythm) can result from alterations in normal
postural relationships of humerus & scapula
HUMERO-THORACIC RHYTHM
• Represented by Global Diagram
• Global diagram is an effective method for displaying humerothoracic positions because it allows
presentation of both planes of elevation ("longitudes") & angles of elevation ("latitudes")
• Details of humeral motions can be indicated on a global diagram as a series of points or arrows
• Codman's Paradox
• Codman proposed that completely elevated humerus could be shown to be in either
extreme external rotation or in extreme internal rotation by lowering it either in coronal or
sagittal plane, respectively, without allowing rotation about humeral shaft axis
• Using global diagram to examine Codman's paradox
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ORTHOPAEDI UI
• Carry out movement sequence below without allowing rotation about humeral shaft axis:
1. Place arm at side with forearm internally rotated across stomach
2. Elevate arm 180o in plus 90o thoracic (sagittal) plane
3. Lower arm 180o to side in 0o (coronal) plane
o
Note that forearm now points 180 from its original position
Kinematic Descriptors
• Shoulder motion can be described/modeled using 3 possible systems

1. Euler/Cardan angles - describes pathway of motion in 3 planes
2. Joint Co-ordinate System - segment position is in relation to joint itself, rather than
coronal or sagittal planes
3. Helical Screw Axis
• Most accurate
• During an arc of movement position & orientation of axis will change & path
followed by axis defines arc of movement
INDIVIDUAL JOINT MOTION

Glenohumeral joint
• Minimally constrained ball & socket joint

• Motion
• Rotation
• Translation (gliding)
• Rolling (combination of rotation & translation)
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ORTHOPAEDI UI
Stabilisers
• Static
Humeral version - neck-shaft angle 135o, head retroverted 30o
1.
o o
2.
Glenoid version - 7 retroversion, 5 superior tilt
3.
Articular conformity
4.
Glenoid labrum
• Deepens socket by 5-9 mm
• Resticts translation
• Attachment for glenohumeral ligaments
5. Intra-articular pressure - may have a role in centering humeral head, particularly in
neutral or early ranges of motion
6. Glenohumeral ligaments & capsule
7. Coracohumeral ligament - primary restraint to inferior translation of adducted arm & to
external rotation
• Dynamic
1. Joint compression - from synchronised contraction of rotator cuff muscles
2. Increased capsular tension by direct attachment of rotator cuff to capsule
3. Biceps tendon
• When arm internally rotated, tension on biceps reduces anterior humeral head
translation
• When arm externally rotated, biceps limits posterior translation
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ORTHOPAEDI UI
4. Scapular rotators - altered scapulothoracic motion may be related to glenohumeral

instability
5. Proprioception
Acromioclavicular joint
• Plane, synovial joint with meniscus

• Motion
1. Forward rotation of clavicle relative to scapula - constrained by conoid ligament
2. Backward rotation - constrained by trapezoid ligament
3. Axial rotation - constrained by both ligaments
Sternoclavicular joint
• Synovial joint, meniscus

• Motion
1. Protraction/retraction
2. Elevation/depression
3. Rotation
o
o Total motion = 40 during arm elevation
o Motion is reciprocal with ACJ motion
Stabilisers
0. Costoclavicular ligament
1. Sternoclavicular ligament
2. Subclavius muscle (from costochondral junction of 1st rib to subclavian groove
undersurface of clavicle)
Scapulothoracic articulation
• Motion
1. Protraction/retraction
2. Elevation/depression
3. Rotation
• Lack of true joint allows for wide range of shoulder motion
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ORTHOPAEDI UI
• Range of glenohumeral to scapulothoracic motion 2:1

• Scapula twists at maximal arm elevation (coracoid moves up)
KINETICS
•
o
Maximum joint reaction force is 90% of body weight at 90 scapular plane elevation
TRAUMATIC SHOULDER DISLOCATIONS
Classifications
• Direction
• Most often anterior, but may be posterior, inferior (“luxatio erecta”), or rarely, intrathoracic
• Chronicity
• Acute
• Chronic: unreduced dislocations presenting or diagnosed after 3/52
• Mechanism
• Traumatic: subluxation or true dislocation
• Atraumatic: voluntary or involuntary
Radiographs
• X-rays
• Lateral view
• Shows glenoid fossa well, TRO posterior dislocation
• Axillary view
• Best
• Evaluates
• Head compression #
• Lesser tuberosity
• Glenoid #
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ORTHOPAEDI UI
• Posterior dislocation
• Anterior instability
• Os Acromiale
• Scapular Y or tangential view
• West Point view
• Tangential view of anteroinferior rim of glenoid

• Evaluates anteroinferior glenoid
• Shows Bankart lesion
• Internal rotation AP view
• Evaluates humeral head
• Shows Hill-Sachs lesion
• Styker notch view
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ORTHOPAEDI UI
• Shows Hill-Sachs lesion

• Valpeau view
• CT
• Impaction lesions of glenoid rim
• MRI
• Rotator cuff pathology but not indicated for acute trauma
Anterior Dislocations
• Most common (95%)
• Usually adolescents & young adults (12-50 yrs)
Mechanism of injury
• Forced external rotation of shoulder while arm is abducted, levering humeral head against
anterior capsule
• As restraining effect of anterior glenoid labrum & capsule exceeded, head of humerus dislocates
anteriorly & usually comes to rest below coracoid process
• Pathology
• In ~85% of patients, glenoid labrum (& attached IGHL) is detached from anterior glenoid
rim (Bankart lesion)
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ORTHOPAEDI UI
• Remaining cases occur with interstitial stretching or frank rupture of capsule without
significant detachment of labrum
• Glenoid rim #
• Superior labral lesion
• Compression # of posterolateral margin of humeral head (Hill Sachs lesion)
Clinical
• Affected arm kept at side of body in external rotation

• Humeral head palpable anteriorly in subcoracoid position & loss of normal lateral & posterior
contours
• May be axillary nerve palsy
• Less commonly, other neurovascular injuries
Treatment
• Prompt reduction Rx of choice

• Closed reduction
• Key to reduction: muscle relaxation -> GA may be necessary
• Reduction maneuvers
• Traction-countertraction maneuver (modified Hippocrates)
• Upper or distal arm traction, with gentle rotation
• Milch technique
• Supine position
• 1 hand fixes humeral head as the other hand gently abducts arm into
overhead position
• As a consequence, instead of moving downward as arm moves upward,
head rotates in place
• Once arm in complete abduction, all cross stresses exerted by all
muscles have been eliminated
• Head can be gently pushed over rim of glenoid, & dislocation reduced
• Modifications
• External rotation of arm
• Presents thinnest profile of humeral head to glenoid &
tilts greater tuberosity backwards
• Scapular manipulation technique
• An assistant uses 1 hand to push inferior tip of scapula
medially
• Stimson's technique
• Modification of Kocher's method
• Not recommended -> #
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ORTHOPAEDI UI
• Key: avoidance of traction

• Elevate patient's elbow above midcoronal plane
• Then gently & slowly externally rotate it using a hand placed on patient's
wrist
• Slowly abduct extremity during this process to ~90°
• Reduction usually accomplished by these maneuvers, but if not, then
arm is adducted fully across chest & internally rotated as in last 2
maneuvers of Kocher's method
• Postreduction Mx
• Obtain confirmatory radiographs
• Immobilisation
• Immobilize shoulder in a sling or shoulder immobilizer
• Position of immobilisation
• ? in external rotation
• Duration of immobilization
• Controversial
• Early mobilisation to tolerance vs ~4-6/52
• Patients >40 yrs should be immobilized for less time because
stiffness & rotator cuff injuries more likely than recurrent
instability
• Rehab emphasizes on strengthening rotator cuff
• Goal - to avoid recurrent dislocations without excessive stiffness
• Surgical reduction
• Indications
• Shoulder dislocations may be irreducible in absence of #, usually because of
soft-tissue interposition in joint or severe muscle spasm
• Open reduction indicated when closed reduction fails in spite of GA
• Approach
• Anterior deltopectoral approach for most dislocations, although associated
injuries or wounds may warrant alternate approach
• Postop Mx
• Depends on pathology & stability after reduction & repair of any injured soft
tissues
• Generally, immobilization in shoulder immobilizer or sling immediately postop
• Pendulum exercises started in 1-2/7, & graduated rehab program instituted within
2/52
• Less stable injuries require longer periods of immobilization
Posterior Dislocations
• Uncommon (2-4%)
• Initial diagnosis missed in 60-80% of cases
Mechanism of injury
• Posteriorly directed force acting on an adducted & internally rotated humerus

• Can also result from violent muscle contractions & therefore may be seen after grand mal
seizures, electroshock Rx, or electrocution injuries
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ORTHOPAEDI UI
Clinical
• Shoulder usually held internally rotated, & unable to abduct or externally rotate
• Fullness of humeral head posteriorly
• Late diagnosis - atrophy of shoulder musculature despite return of limited abduction & external
rotation
Treatment
• Reduction maneuvers: rotate arm to neutral position & gently lever humeral head anteriorly into
glenoid
• Postreduction Mx
• Stable reduction - sling
• Significant instability - immobilization in neutral or slight external rotation
• Rehab
• Chronic dislocations
• May be irreducible by closed methods
• Can present with muscle contracture, periarticular fibrosis, associated #, or heterotopic
bone formation
• Open reduction + joint debridement & attempts at soft-tissue repair or muscle
advancement into defect in humeral head
Complications
• Recurrent dislocation
• Most frequent Cx
• Rate of recurrence is age-dependent
• <20 yrs: 70-90%
• 20-40 yrs: 60%
• >40 yrs: 10%
• Prevention
• Patient education about what joint positions are likely to be unstable based on
original direction of dislocation
• Adherence to well-designed rehab program that strengthens weakened shoulder
muscles
• Unstable joints despite these precautions warrant surgical Rx for chronic instability
• Neurologic injuries
• Usually transient
• Brachial plexus injuries uncommon, most often neurapraxias
• Isolated axillary nerve palsies usually resolve within 3/12
• In the interim, shoulder should be supported to prevent persistent inferior subluxation &
stretching of soft tissues
• Rotator cuff injuries
• More likely in older patients in association with glenohumeral dislocations
• Should be suspected in patients >40 yrs with persiste
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ORTHOPAEDI UI
Shoulder Instability
Definitions
• Laxity
• Capacity of humeral head to be translated or rotated from a reference position
• Detected on physical exam
• Instability
• Inability to maintain humeral head centered in glenoid fossa
• Determined primarily from history & confirmed with reproduction of symptoms on
physical exam
SHOULDER STABILISERS y
• Static restraints (joint, bone, soft tissue)

• These keep shoulder in joint when at rest
1. Intracapsular pressure: normally intracapsular pressure of shoulder is -ve
2. Suction effect: glenoid labrum acting on humeral head like a “plunger”
3. Adhesion-cohesion: between 2 wet smooth surfaces
4. Glenoid version: may have bearing on a few cases with recurrent posterior
dislocation but exception is in patient with congenital glenoid dysplasia
5. Humeral retroversion
• Normal 21-30º
• Some studies -> significant reduction in patients with recurrent anterior
dislocation
6. Labrum
• “Chock block” to humeral head movement
• Increases depth of glenoid by 50%
• Increases surface area
7. Ligaments
• Coracohumeral ligament
• Superior glenohumeral ligament (SGHL)
• Middle glenohumeral ligament (MGHL)
• Inferior glenohumeral ligament complex (IGHLC)
• Posterosuperior capsule
8. Capsule
Dynamic constraints
Keep shoulder in joint during activity
0. Rotator cuff: concavity compression - active compression of humeral head into
glenoid fossa
1. Long head of biceps: biceps much more active in patients with recurrent
dislocation
2. Proprioception
• Lephart et al 1994 studied proprioception in 3 groups of patients: normal,
unstable, reconstructed shoulders
• Proprioception significantly reduced in unstable shoulders but returned to
near normal in reconstructed
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ORTHOPAEDI UI
CLASSIFICATIONS
TUBS & AMBRI (Matsen)
• Matsen describes 2 categories of anterior instability

• Often clinical overlap
TUBS or “Torn Loose” AMBRI or “Born Loose”

Traumatic aetiology Atraumatic: minor trauma
Unidirectional instability Multidirectional instability may be present
Bankart lesion is the pathology Bilateral: asymptomatic shoulder is also loose
Surgery is required Rehabilitation is Rx of choice
Inferior capsular shift: surgery required if conservative measures fail
Voluntary Dislocator
• Often a/w psychiatric condition or alternative gain

• Desire to voluntarily dislocate shoulder cannot be treated surgically
Multi-directional Instability (MDI)
• Definition: abnormal amount of excursion of humeral head on glenoid in all directions

• Implies 3-way subluxations or dislocations either anteriorly, posteriorly, or inferiorly
• Classification - Neer
Group I Antero-inferior dislocation

Posterior subluxation
Group II Postero-inferior dislocation
Anterior subluxation
Group III Global dislocation
• MDI presents as primary instability which is most obvious in 1 direction
PATHO-ANATOMY
Traumatic
Capsule Bankart lesion
Stretch of capsule in continuity
Congenital laxity
Wide rotator interval

Glenoid Bony Bankart
Ideburg-1 #
Crevassing
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ORTHOPAEDI UI
Labrum Bankart tear

Posterior labral tear
LHB SLAP tear
Rotator cuff Supraspinatus tear
Subscapularis avulsion
Humerus Tear of ligamentous insertion (HAGL)
Greater tuberosity #
Hill-Sachs lesion
• Bankart lesion
• Avulsion of anteroinferior glenoid labrum at its attachment to IGHL complex
• Felt to result from anterior shoulder dislocation & felt to be primary lesion in recurrent
anterior instability
• Obligatory concomitant capsular disruption, with stretching or elongation of IGHL; in upto
30% IGHL will heal in a redundant position
• Hill-Sachs lesion
• Posterolateral humeral head indentation #
• Resulted from anterior shoulder dislocation, as soft base of humeral head impacts
against relatively hard anterior glenoid
• Occurs in 35-40% of anterior dislocations & upto 80% of recurrent dislocations
• May destabilizes glenohumeral joint & may predispose to further dislocation
• Rotator interval
• A triangular portion of shoulder capsule which lies between supraspinatus &
subscapularis tendons
• Interval capsule reinforced by superior glenohumeral & coracohumeral ligaments
• Acts to limit flexion & external rotation
• Tears of rotator interval capsule
• May mimic rotator cuff tears
• Impingment signs may be present along with biceps tendon tenderness
• Posterior & inferior instability
• SLAP lesion (Superior Labrum Anterior & Posterior)
• Detachment lesion of superior aspect of glenoid labrum, which serves as insertion of long
head of biceps
• May occur while eccentric load is being placed through biceps (eg. when an athlete loses
control of a weight while lifting)
• Often a/w clicking, locking &/or a feeling that shoulder is ‘not right'
• Originally reported by Snyder et al
Type Description Treatment

I Fraying with intact anchor Arthroscopic debridement
II Detachment of biceps anchor Arthroscopic/open
stabilisation
III Bucket-handle tear of superior labrum, biceps intact Arthroscopic debridement
IV Bucket-handle tear of superior labrum into biceps Repair or tenodesis
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ORTHOPAEDI UI
Atraumatic
• Definitive aetiology still not clear

• Loose redundant inferior capsule
• Deficiency in interval between subscapularis & supraspinatus
• Suboptimal muscle control of shoulder function
• Abnormalities in connective tissue
• Associated with generalized ligamentous laxity
CLINICAL CLASSIFICATION
When? Acute
Neglected (chronic)
Recurrent
How? Traumatic
Atraumatic
Voluntary
Direction? Anterior
Posterior (~2% of shoulder dislocations)
Inferior - luxatio erecta
Multidirectional
Degree? Dislocation
Subluxation
Why? Torn loose
Born loose
CLINICAL ASSESSMENT
History
• Symptoms during arm abduction & external rotation
• May be a period of arm losing sensation & strength
• Posterior instability occurs with arm flexed, adducted, & internally rotated, eg. when pushing a
heavy cart or pushing open a door
• Inferior instability may become symptomatic when carrying heavy objects
• Atraumatic instability may have family history & history of other joint problems eg. recurrent
atraumatic patellar dislocations
• MDI affects overhead throwing atheletes, gymnasts, swimmers
Physical exam
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ORTHOPAEDI UI
• Rotator cuff
• 3 major components tested by isometric examination for strength & comfort
1. Elevation in internal rotation for supraspinatus
2. External rotation for infraspinatus
3. Internal rotation with hand on stomach for subscapularis
Laxity tests [See Shoulder Examination]
0. Inferior draw “Sulcus sign” - hallmark of multidirectional instability
1. Anterior & posterior draw with patient supine (Gerber & Ganz)
Instability tests [See Shoulder Examination]
1. Anterior apprehension test

2. Crank test - continuation of anterior apprehension test; if patient does not wince at full ER
then overpressure is applied
3. Relocation test - once patient feels joint slipping out with anterior apprehension/crank
tests, examiner then pushes backwards & relocates joint
4. Release test
5. Jerk test - elevate & internally rotate & adduct arm, push posteriorly, subluxing shoulder
posteriorly; then abduct & shoulder relocates with a jerk
6. Load & shift test
• Determines competence of glenoid concavity
• Patient supine, examiner abducts & ER shoulder & pushes from behind/front
while pressing humeral head into glenoid fossa
• Grade 1 = anterior translation to edge of glenoid
• Grade 2 = subluxation over front of glenoid, easily relocatable
• Grade 3 = full clunk of dislocation & relocation
• This can dislocate shoulder fully & thus better on anaesthetised patient
• O'Brien's sign
• Forward flexion in pronation -> pain
• Forward flexion in supination -> reduced pain
• Neurovascular examination
• All nerves can be affected but most commonly axillary & musculocutaneous nerves
• Generalized ligamentous laxity
• Elbow & knee hyperextension, ability to place thumb to forearm, MCPJ hyperextension
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ORTHOPAEDI UI
Investigations
• X-rays
1. True AP
2. Lateral (axillary)
• Axillary or Y-scapular views
• Allows evaluation of
• Head compression #
• Lesser tuberosity
• Glenoid #
• Posterior dislocation
• Normally there is posterior translation of humeral head when arm
in extension & external rotation due to tension in anterior capsule
& ligaments
• Posterior translation absent in shoulders with anterior instability
• Os Acromiale
West Point view
Apical oblique: to visulaize anterior/inferior glenoid rim for # or calcification following dislocation
Stryker notch view
AP in internal rotation view
CT can help define humeral & glenoid deficiencies or abnormalities
US/MRI to evaluate rotator cuff in individuals >40 yrs who have weakness or pain on muscle
testing
EUA/Arthroscopy (gold standard)
o Labral detachment
o Articular injury to either glenoid or humeral head
o Extent of capsular redundancy
o Status of rotator cuff
NATURAL HISTORY
Traumatic anterior instability
• Adolescent (<20 yrs)

• Recurrence rates of 70-90%
• When patient's proximal humeral growth plate is open, up to 100% rate of redislocation
• Incidence virtually unaffected by length of immobilization or maintenance of
physiotherapy program
• Often have Bankart lesion
• Young adults (20-40 yrs)
• Rate of redislocation 50-60%
• Kirkley et al Arthroscopy Vol 15(5)1999: 507-514
• Prospective randomised study
• Comparing effectiveness of traditional Rx with immediate arthroscopic
stabilisation in young patients who have sustained a 1st traumatic anterior
dislocation of shoulder
• 40 skeletally mature patients <30 yrs of age randomly allocated to
1. Immobilisation for 3/52 followed by rehab (group T)
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ORTHOPAEDI UI
2. Arthroscopic stabilisation (group S)

At 24/12, statistically significant difference in rate of redislocation
T = 47%, S = 15.9%, P = 0.03
>40 yrs
Redislocation rate <10%
However, 15% have rotator cuff tear at initial dislocation & high incidence of subscapularis &
capsular avulsion from lesser tuberosity
Extent of soft-tissue injury sustained not limited to initial dislocation, but rather progressive with
each subsequent dislocation
Baker et al 1990 examined 45 acute traumatic dislocations arthroscopically
Group I 6/45 Torn capsule, stable to EUA, no labral tear, small haemarthrosis
Group II 11/45 Partial labral tear, subluxation on EUA, moderate haemarthrosis
Group III 28/45 Anterior labral tear, dislocatable on EUA, large haemarthrosis
(18 of these patients had a Hill-Sachs lesion)
Atraumatic instability
• Natural history less clear
TREATMENT
Non-operative
• 1st line of Rx
• For most first-time shoulder dislocations
• Strengthening program should use isometric rotator cuff, deltoid, & scapular stabilizer
exercises
• Once strength & ROM equal to normal side & after a healing period of 3/12 -> return to
preinjury activities
• Recurrent anterior instability after traumatic dislocation
• Requires limitation of activity, restrictive brace, more strengthening
• Structured rehab program which strengthens muscles & improves proprioception around
glenohumeral joint
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ORTHOPAEDI UI
• This must be continued for at least 1 yr before considering operative intervention

• Posterior instability
• Very rare; 2-12% of all shoulder instability cases
• Many cases are atraumatic & best treated with physical rehabilitation
• MDI
• More complex to manage
• Usually atraumatic, resulting from combination of excessive tissue compliance,
muscular discoordination, & inadequacy of glenoid concavity
• Often a/w pain
• Rehab & education standard for most situations
• Better success rate than traumatic instability
Surgical
• Indications
• No hard criteria, but
• Young patient <30 yrs
• 2 dislocations in 2 yrs
• Care must be taken in performing surgery for this condition as over-tightening of structures on 1
side of joint can produce dislocation or subluxation on opposite side
• Emphasis now on anatomical repair/reconstruction
• Antero-inferior instability
• Bankart repair
• SLAP repair
• Putti Platt: shortens anterior capsule & subscapularis by overlapping repair
• Magnussen-Stack: transposition of subscapularis tendon to greater tuberosity
• Bristow: reinforces anteroinferior capsule by redirecting other muscle across front of joint
with transfer of coracoid process to anterior aspect of scapular neck
• Neer inferior capsular shift
• Laser/thermal capsular shrinkage has been tried recently
• ~10% recurrence at 3-7 yrs
• Postero-inferior instability
• Postero-inferior capsular shift
• Posterior glenoid osteotomy
• Internal rotation humeral osteotomy
• Posterior bone block - to deepen “chock block” effect of posterior glenoid rim
• Boyd & Sisk procedure - LHB detached & re-attached around posterior glenoid rim
• Glenoid osteotomy
• MDI
• Assessment should include effectiveness of glenoid concavity, directions of true
instability (not just laxity), & patient motivation
• Voluntary subluxation or dislocation -> poor results from surgical stabilization -> surgery
not recommended
• Capsular shift - 85-90% satisfactory long term results
• Laser/thermal capsular shrinkage of posterior, inferior, & anterior capsules
SURGERY
EUA
• Can help quantify degree & direction of instability
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ORTHOPAEDI UI
Anterior reconstruction
• Open (gold standard, MDI) vs arthroscopic surgery

• Open repair of Bankart lesion
• Incision from coracoid distally towards axilla
• Develop plane of deltopectoral groove (cephalic vein)
• Retract deltoid laterally & pectoralis major medially
• Retract conjoint tendon medially or osteotomize coracoid process for more exposure
(musculocutaneous n.)
• Mobilize subscapularis by splitting it or detaching it close to insertion (axillary n. &
circumflex arteries)
• Incise capsule in T shape
• Retract humeral head laterally
• Reattach labral lesion at 2, 4, 6 o'clock positions
• Plicate capsule
• Tighten rotator interval
• Subscapularis closed without tension
• Close wound in layers
• Repair of SLAP lesion if present
• Inferior capsular shift
Large Hill-Sachs defect
• McLaughlin procedure - infraspinatus muscle is inserted into defect

• Subscapularis/lesser tuberosity for large reverse Hill-Sachs lesions
• Weber osteotomy to correct retroversion
Postop rehabilitation
• 0-3/52
• Sling day & night except when doing exercises
• Elbow extension exercises
• Pendular exercises
• External rotation to neutral only (for 3/52 to protect Bankart & subscapularis repair)
• Submaximal isometric external rotator exercises
• 3-6/52
• Passive flexion building up to 140º by 5/52
• External rotation to 30º by 6/52
• Continue scapular strengthening exercises
• 6-12/52
• Passive ER to 60º by 12/52
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ORTHOPAEDI UI
• Strengthening exercises
• Proprioceptive training
• 3/12
• Non-contact sports can start
• Full ROM should now be achieved
• 4/12
• Power & endurance exercises
• 8/12
• Contact sports allowed
• 12/12
• Overhead sports allowed
Complications
• Nerve injury
• Musculocutaneous nerve: rare but increased risk if coracoid osteotomy
• Axillary nerve
• Limited movement
• Rare after anatomical repair
• Care with elite throwing athletes who will have excessive external rotation preop
• Recurrence
• Meta-analysis of 53 papers (3187 patients) following surgical repair showed average
redislocation rate of 3%
• Infection
• Rare
• Arthritis
• Can occur after too tight a closure, as seen with Putti-Platt
• Hovelius 1996 found 20% had radiographic evidence of OA at 10 yrs
• Incidence not related to number of dislocations
Rotator Cuff Disease
Anatomy of Supraspinatus
• Bipennate muscle
• Origin: supraspinous fossa of scapula
• Insertion: greater tuberosity of humerus by a 2 x 1 cm ‘footprint’
• Anterior to tendon -> rotator interval of capsule, strengthened by coracohumeral & sup.
glenohumeral ligaments
• Posteriorly confluent with tendon of infraspinatus
• Deep surface of tendon merges with superior capsule of shoulder joint, in direct contact with
humeral head
• Superiorly coracoacromial arch - acromion, coracoacromial ligament & acromioclavicular joint,
with subacromial bursa between arch & tendon
BACKGROUND
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ORTHOPAEDI UI
• A continuum of disease which include

• Subacromial impingement of RTC
• Partial RTC tear
• Complete RTC tear
• Cuff tear arthropathy
• Accounts for 1/3 of referrals to shoulder clinics
AETIOLOGY
• Several theories
• Avascularity of tendon
• An avascular area in supraspinatus tendon just proximal to its insertion, corresponding to
area of degeneration & rupture
• Lindholm & Moseley -> this was where anastomosis between blood vessels from bone &
those from muscle belly
• Rathburn & McNab ->
• With arm adducted & neutral, there is constant pressure of humeral head on
supraspinatus, ‘wringing’ blood out of tendon in critical area
• This precedes & is not result of degenerative changes
• Mechanical wear
• Neer felt this is a mechanical process secondary to progressive wear
• Found to be only anterior aspect of acromion involved with or without osteophytes from
AC joint
• Bigliani has described 3 types of acromion - flat, curved (42%), hooked
• A cadaveric study of 140 shoulders -> 73% of rotator cuff tears were in type 3 hooked
acromions
• Trauma
• Macro or micro trauma
PATHOLOGY
• Abrasion of rotator cuff due to narrowing of bony tunnel through which tendon passes
• 90% of disease occurs in anterior 1/2 of final 3 cm of supraspinatus tendon
• Associated changes
• Degenerative changes in ACJ, with inferior osteophytes
• Morphological changes in anterior aspect of acromion (Bigliani)
• Subacromial impingement is a continuum of pathology that in its final stages may be a/w full-
thickness RTC tears
• Tears typically begin on bursal surface or within tendon substance (cf on articular surface due to
tension failure in young athletes)
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ORTHOPAEDI UI
CLASSIFICATIONS
• Neer’s Classification of subacromial impingement syndrome

• Stage I
• Reversible oedema & inflammation of supraspinatus tendon
• Excessive overhead use in young adults age <25 yrs
• Treat conservatively with good prognosis
• Stage II
• Fibrosis of rotator cuff
• Permanent & irreversible changes to rotator cuff, causing pain not relieved by
rest
• Patient usually aged 25-40 yrs
• Often needs subacromial decompression
• Stage III
• Partial or full thickness tear in rotator cuff
• Bony alteration of anterior acromion with bony spurs
• Patient usually aged >40 yrs
• Classification of partial thickness tears
According to site Articular or bursal side

According to thickness Grade I <1/4 thickness
Grade II <1/2 thickness
Grade III >1/2 thickness
• Classification of rotator cuff complete tears
Small <1 cm
Moderate 1-3 cm
Large 3-5 cm
Massive >5 cm
• Describe tear by shape = split, L-shaped, reverse L-shaped, crescentic or

trapezoidal
CLINICAL
Clinical presentation of impingement
• History
• Patient 40-50 yrs
• Pain
• Insidious onset, exacerbated by overhead activities & throwing
• Pain over greater tuberosity radiating onto chest wall, superiorly to trapezius or
down to elbow, on reaching out with shoulder, exaggerated by internal rotation
• Difficulty sleeping on affected side
• Examination
• Mild tenderness over greater tuberosity
• Minimal rotator cuff wasting
• Painful arc of abduction 70-120
o
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ORTHOPAEDI UI
•
o
Exaggerated by internal rotation at 90 of elevation (Hawkin’s test)
• Internal rotation limited
• External rotation unlimited
• Neer's test & Neer's sign +ve (injection of local anaesthetic into subacromial space
eliminates pain)
• Power normal
• Beware young sportsperson presenting with impingement, he may have instability of
shoulder -> functional impingement
Clinical presentation of a tear in rotator cuff
• ‘Grey hair = cuff tear’

• History
• Age over 40
• Labourer
• History of shoulder injury
• Loss of power in elevating arm
• Examination
• Faulty scapulohumeral rhythm
• Depending on which tendon torn
• Infraspinatus = +ve Hornblowers sign
• Subscapularis = +ve Gerbers lift off test
• Supraspinatus
• If complete tear, inability to abduct 1st 15 & unable to abduct past 60
o o
• When attempting to do so, whole shoulder girdle elevates

• Drop arm sign
• Pain & loss of power on Jobe's test
INVESTIGATIONS
X-ray
• Views
• AP
• Axillary - unfused os acromionale
• Supraspinatus outlet - morphology of acromion
• May be normal
• Abnormal in stage III
• May be an acromial spur
• Sourcil sign - sclerosis on undersurface of acromion, looks like an eyebrow
• Degeneration in AC joint
• Small cysts on greater tuberosity of humerus
• Humeral head may migrate upwards, breaking ‘Shentons’ line of shoulder
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ORTHOPAEDI UI
Arthrography
• Obselete, but can show a full or partial thickness tear

• Does not give enough info about size or shape of tear
Ultrasonography
• May show a full thickness tear

• Cheap & noninvasive, but operator dependent
MRI
• Ix of choice for rotator cuff tears

• Less useful in impingement as high level of false +ve
• Useful for complete tears
Shoulder Arthroscopy
• More expensive than MRI but more specific for impingement & partial thickness tears
• A kissing lesion can sometimes be seen on deep surface of acromion
• If proceeding to surgery, works out cheaper than MRI
MANAGEMENT
Management of subacromial impingement
• Conservative
• Activity modification
• Physiotherapy
• Strengthening exercises to rotator cuff using Therabands
• Leads to centering of head, reducing impingement
• Injection of subacromial space with steroid & local anaesthetic, reducing inflammation
• If good response, repeat up to 3 injections in total
• In rats, more than this has led to permanent tendon damage
• Temporary relief
• Surgery
• Indications: failure to respond to conservative measures despite improvement
immediately after subacromial injection
• Arthroscopic subacromial decompression with or without AC joint excision
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ORTHOPAEDI UI
• Criteria required
1. Proven impingement
2. Unscarred bursa & highly distensible for a good view
3. Well trained surgeon
4. Ability to change to open surgery if necessary
• Technique
Shaver from anterolateral portal or posterior portal
Shave off attachment of coracoacromial ligament, burr down bone,
starting at front, avoid acromial artery, along anterior border of acromion
Results: see literature search below
Open subacromial decompression with or without AC joint resection of 1.5-2 cm of distal
clavicle
For persistent impingement syndrome refractory to 6-12/12 of nonoperative Rx & in conjunction
with RTC repair
Technique
Beach chair position
Skin incision
• Strap incision between tip of acromion to ACJ if excision of ACJ
planned
• Otherwise, along lateral border of acromion to coracoid
Superficial dissection
• Incise & completely mobilize subcutaneous tissue
• Periosteal incision proximally
• Incise delto-trapezial fascia longitudinally
• Identify & split deltoid longitudinally down anterolateral
raphe on acromion
• Elevate deltoid fibres as 2 flaps off anterior acromion
• Deltoid incision distally
• Continue to incise through deltoid raphe distally but not
more than 4-5 cm below tip of acromion
Deep dissection
• Excise coracoacromial ligament to expose undersurface of
acromion
Acromioplasty
• 2 portions resected & bevelled
1. Portion which protrudes beyond anterior edge of acromion ~5
mm
2. Undersurface of acromion to convert it to type I
If indicated
ACJ resection
Complete periosteal dissection across ACJ
Strip periosteal flaps both anteriorly & posteriorly
Small Homan retractors on either side of distal clavicle
Palpate & protect conoid & trapezoid ligaments
Transect 1-1.5 cm of distal clavicle
Bursectomy
Using facial scissors, remove bursa from posterior to
anterior
Greater tuberosity debridement
Prominent tuberosity can be excised if there is further
impingment
Rotator cuff repair (see below)
Results - 85% success rate
Cx
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ORTHOPAEDI UI
Loss of anterior deltoid function

Worst common Cx
Due to axillary nerve injury (5 cm distal to lateral acromion) or detachment of deltoid
Infection, seroma, haematoma, synovial fistula, biceps rupture, pain,
stiffness
Management of rotator cuff tears

Conservative
• Steroid injection & physio can help in small rotator cuff tears
• If irreparable tears in elderly, occupational therapy can be useful
Surgery
• Indications
• A patient with normal life expectancy, <65 yrs biologically, with a proven rotator cuff tear
<4 cm should have surgery ASAP
• Patients >65 or with tears >4 cm may be considered for surgery by an expert surgeon
• Open repair
• Always perform subacromial decompression
• Small Cuff Tears (<1 cm)
• Approached via Matsen ‘deltoid on’ approach
• Suture side to side
• Moderate Cuff Tears (1-3 cm)

• Same approach
• May excise AC joint
• Release cuff
• Prepare a superficial bone trough to bleeding cancellous bone from where cuff
has been avulsed on humerus
• Stay sutures used to hold cuff
• Cuff reattached using bone anchors of some sort
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ORTHOPAEDI UI
• Preferred technique
• Beach chair position
• Arthroscopy before open surgery
• Skin incision
• Strap incision between tip of acromion to ACJ if excision of ACJ planned
• Otherwise, along lateral border of acromion to coracoid
• Superficial dissection
• Incise & completely mobilize subcutaneous tissue
• Periosteal incision proximally
• Incise delto-trapezial fascia longitudinally
• Identify & split deltoid longitudinally down anterolateral raphe on
acromion
• Elevate deltoid fibres as 2 flaps off anterior acromion
• Deltoid incision distally
• Continue to incise through deltoid raphe distally but not more
than 4-5 cm below tip of acromion
• Deep dissection
• Excise coracoacromial ligament to expose undersurface of acromion
• Cut through bursa anterolaterally, exposing underlying rotator cuff
• Coagulate acromial branch of thoracoacromial artery
• Acromioplasty (see above)
• Rotator cuff repair
• Mobilise rotator cuff by running a finger between cuff & deltoid as far as
possible
• 3 Mason-Allen sutures (5 Ethibond) into cuff
• Make a trough in greater tuberosity
• Drill holes through trough to lateral humerus for bone sutures
• Put sutures through trough & holes to tie on humerus
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ORTHOPAEDI UI
• Large Cuff Tears (3-5 cm)

• Same as above
• Massive tears (>5 cm)
• Only by expert surgeons
• Technique
• McClaughlins technique where cuff sutured to a trough in any part of
humeral head that can be reached
• Subscapularis tendon transposition (described by Cofield)
• Transfer of Latissimus dorsi (Gerber reports good results)
• In general a reasonable approach is
• If tendon can be brought into a trough repair with arm in abduction, repair
it & splint arm in abduction for 6/52
• If tendon cannot be repaired then perform decompression & debridement
• Arthroscopic cuff repair
• Still experimental
• Rehab postop
• Phase 1: protective, protecting repair but regaining movement & prevention of muscle
weakening
• Phase 2: strengthening, when healing secure, & 2/3 normal ROM achieved
• Phase 3: return to work & sport, entry requirements, full ROM, no pain or tenderness
Cuff Tear Arthropathy

• End stage of rotator cuff disease
• Occurs in 4% of those with rotator cuff disease
• Clinical features
• Patient 70-80 yrs

• Severe pain in shoulder
• Inability to reach out
•
o
Range of active elevation only 40-60
• Severe wasting of supraspinatus & infraspinatus
• Effusion anteriorly
• Subluxation of humerus superiorly
• X-rays
• Arthritic humeral head articulating with acromion

• Glenoid arthritic
30
ORTHOPAEDI UI
• Rx
• No absolutely satisfactory answer, possibly constrained total shoulder arthroplasty, but
high risk of Cx
• Laurence in 1991 performed semiconstrained shoulder replacements in 72 patients
• Complete pain relief in 31%
• Minor discomfort in 50%
Calcific Tendinitis
• Tendinitis due to Ca phosphate crystal-induced inflammation
• Cause unknown
• Genetic predisposition
• Autoimmune
• Tendon degeneration
• May be due to ischaemia & reduction in normal inhibitory factors of crystal
deposition
• Calcium phosphate crystals are deposited in degenerated or inflamed soft
tissues
• Deposits of calcium phosphate in supraspinatus tendon near its insertion, other
sites may also be involved
• Symptoms due not to calcium but a florid vascular reaction with which it is
associated
• Resorption of calcium is rapid & it may soften or disappear entirely within a few
weeks
• Clinical
• Predominantly middle-aged women
• Onset
• Dull aching sometimes following overuse
• Spontaneous onset
• Acute stage
• Crescendo pain in shoulder, severe +++
• Usually will not allow movement
• Usually self-limited but can persist for extended period
• X-ray
• Calcification within RTC in subacromial space
• As pain subsides calcification gradually disappears
• Rx
1. Anti-inflammatories & symptomatic Rx
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ORTHOPAEDI UI
2. Physiotherapy
3. Injection of local anaesthetic into subacromial space & needle calcific deposit
4. Aspiration of calcific substance through large bore needle at point of maximal tenderness
5. Surgical decompression
6. Barbotage Method
• Under USS or flouroscopic guidance - 2 large needles - agitation - saline lavage
& steroid injection
Frozen Shoulder
Definition
• Term coined in 1934 by Codman

“Frozen shoulder was characterised by slow onset, pain near the insertion of the deltoid, inability
to sleep on the affected side, painful & restricted elevation & external rotation, & a normal
radiological appearance.”
• Codman's 12 criteria
1. Condition comes on slowly
2. Pain felt near insertion of deltoid
3. Inability to sleep on affected side
4. Painful & incomplete shoulder elevation
5. plus external rotation
6. Restriction of both spasmodic
7. & adherent type
8. Atrophy of spinatii
9. Little local tenderness
10. X-rays -ve except for bony atrophy
11. Pain very trying to every one of them
12. but they were all able to continue their daily habits & routines
• Stiff painful shoulder can be classified into 2 groups
1. Patients with primary frozen shoulders are those who fit Codman's criteria & in whom
all other pathology is excluded
2. Patients with secondary frozen shoulders are those who fit Codman's criteria but in
whom condition is secondary to soft-tissue injury, #, arthritis, hemiplegia, or any other
known cause
Incidence
• Quite rare, 5% (70/1,324) of consecutive new patients attending a shoulder clinic (Bunker et al)
Pathogenesis
• Primary or secondary -> chronic tendinitis -> inflammation involves entire rotator cuff & capsule ->
inflammation subsides -> tissue contracture & adhesion -> stiffness
• Pathology (Fibromatosis)
• Frozen shoulder characterised by fibrosis of shoulder joint capsule histologically similar to
Dupuytren's contracture
• Contracture of coracohumeral ligament that acts as a checkrein to passive glenohumeral
movement & external rotation
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ORTHOPAEDI UI
• Histology of thickened rotator interval tissues

• Nodules & laminae of collagen with high cell population of fibroblasts &
myofibroblasts as identified by immunocytochemistry
• Identical both histologically & by immunocytochemistry with 6 control cases of
palmar Dupuytren's tissue
Natural History
• Classic understanding that frozen shoulder is a disease with 3 phases of pain, stiffening, &
thawing leading to resolution in 2 yrs may be optimistic
• Do patients improve by 2 yrs?
• Shaffer (1992) showed that they did not in a detailed long-term study of natural history of
frozen shoulder
• 50% of patients had either mild pain or stiffness or both at average of 7 yrs after onset of
disease
• None of patients reported pain as more than mild & stiffness mainly in external rotation
• Functional restriction small
Clinical Presentation
• Insidious onset of true shoulder pain & difficulty sleeping on affected side
• Mean age 56 yrs
• M=F
• L=R
• On examination
• Patient may suffer from depression because of relentless night pain
• Usually no wasting
• Deltoid may be wasted as a result of disuse
• May be tenderness lateral to coracoid process (not consistent)
• Active & passive movements markedly restricted with combined elevation <100º
(combined elevation 83.2º)
• External rotation (passive) should be <50% of unaffected side: pathognomonic sign of
frozen shoulder
• Gross limitation of passive external rotation is present only in 3 conditions: arthritis,
locked posterior dislocation, & frozen shoulder (average ER 9.4º)
• Internal rotation similarly restricted both actively & passively; patient can just reach
buttock level
Associated Conditions
• Diabetes (incidence of frozen shoulder)

• NIDDM 10-20%
• IDDM 36%
• 42% of patients with bilateral frozen shoulder diabetic
• Dupuytren’s disease
• Bunker examined hands of 50 patients -> 29 of 50 patients had a pit, nodule, or band of
Dupuytren's contracture
• Elevated serum lipids
• In one study, fasting serum lipid levels -> significant elevation of cholesterol & triglyceride
in patients with frozen shoulder
• Elevated serum lipid levels also found in patients with Dupuytren's contracture, cardiac
disease & diabetes
• Minor trauma, eg. following Colles' #
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ORTHOPAEDI UI
• Anti-epileptics
• Frozen shoulder has been recorded in patients recovering from neurosurgery
• Phenytoin a/w Dupuytren's disease
• Phenobarbitone a/w frozen shoulder
• Metallomatrix Proteinase Inhibitors (MMPI)
• Patients developed bilateral frozen shoulder following administration of MMPI for gastric
carcinoma
Diagnostic Tests
• FBC/ESR & HLA-B27 normal

• X-rays, by definition, must be normal, although some disuse osteopenia allowed
• Arthrogram
• Neviaser (1962) showed characteristic reduction in joint volume with a lack of filling of
axillary fold & subscapular recess (rotator interval)
• MRI
• Emig et al examined 9 patients with frozen shoulder -> capsule was thickened, averaging
5.2 mm thick in frozen shoulder group against 2.9 mm thick in control group (p < 0.01)
• Arthroscopy
• Joint volume reduced
• Subscapularis recess obliterated
• Rotator interval often obliterated with scar tissue covered in a highly vasculitic synovium
with papillary infolding
• Axillary recess tight & of reduced volume
• No adhesions
• Surgical exploration (Bunker et al)
• Coracoacromial ligament always normal
• Abnormal thickening in rotator interval area which is distorted by scarring & contracture of
coracohumeral ligament
• Superior edge of subscapularis tendon & anterior edge of supraspinatus tendon highly
abnormal
• If arm is externally rotated, this scarred area tightens & can be seen to be acting as a
checkrein to external rotation
• Division of this scarred area allows immediate & complete external rotation in majority of
patients
• Scarred area highly vascular & when divided bleeds forcefully
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ORTHOPAEDI UI
Treatment
• Physiotherapy
• Steroid Injection
• Steroid injections have been given empirically in frozen shoulder
• Some studies show beneficial effect from use of intra-articular steroids
• Manipulation Under Anaesthesia
• Charnley (1959) manipulated frozen shoulders of 35 patients
• Pain relief -> most important result of manipulation
• Duration of symptoms after manipulation lasted for average of 10/52, no matter how long
symptoms had been present before manipulation
• Charnley insisted on 1 matter of technique: external rotation should be released
before abduction was attempted or dislocation could occur
• In a carefully controlled study, it was shown that
• 75% of patients obtained near-normal range of motion
• 79% were relieved of their pain
• 75% returned to work within 9/52 of manipulation
• Diabetics have poor response to manipulation - Janda & Hawkins -> any improvement in
movement & diminution in pain disappeared by 4/52 after manipulation & suggested that
manipulation should not be attempted in these patients
• Open Surgical Release (see surgical findings above)
• Ozaki Release
• Gridiron incision (coracoid -> clavicle) -> spread deltoid -> divide CHL & clear
RCI with ronguer/duckbill (inside out)
• Beware LHB under CHL
• Simple, safe, effective
• Arthroscopic Surgical Release
HIP
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ORTHOPAEDI UI
ANATOMIC CONSIDERATIONS
A ball & socket synovial joint
Acetabulum
• Formed from confluence of ischium, ilium, & pubis at triradiate cartilage

• Cavity faces obliquely forward, outward & downward
•
o o
A line through circumference is at 40 opening posteriorly from sagittal plane & at 60 from
transverse (horizontal) plane
• Labrum deepens acetabulum & increases stability of joint
Femoral head
• Forms 2/3 of a sphere

• 40% of femoral head is covered by bony acetabulum at any position of hip motion
• Articular surface thicker on mediocentral part & thinnest on periphery
• Joint reaction force usually acts on superior quadrant
• 70% articular surface involved in load transfer
Femoral neck
•
o o o
Neck shaft angle mostly 125 , but varies between 90 & 135
• >125 = coxa valga
o
• <125 = coxa vara

o
•
o
Angle of anteversion ~12 in adults
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ORTHOPAEDI UI
Joint capsule
• Formed by thick longitudinal fibers supplemented by much stronger ligamentous condensations

(iliofemoral, pubofemoral, & ischiofemoral ligaments) that run in a spiral fashion, preventing
excessive hip extension
Blood supply of femoral head & neck
• Arterial supply of proximal end of femur in 4 groups

1. Extracapsular arterial ring (trochanteric anastomosis)
• Located at base of femoral neck
• Formed posteriorly by a large branch of medial femoral circumflex artery &
anteriorly by branches of lateral femoral circumflex artery
• Superior & inferior gluteal arteries minor contributions
2. Ascending cervical branches
• Of extracapsular arterial ring on surface of femoral neck
• Anteriorly, penetrate capsule at intertrochanteric line, & posteriorly, pass beneath
orbicular fibers of capsule
• Pass upward under synovial reflections as retinacular arteries -> many small
branches into metaphysis of femoral neck
• Can be divided into 4 groups: anterior, medial, posterior, lateral
• Lateral group provides most of blood supply to femoral head & neck
3. Subsynovial intra-articular arterial ring
• At margin of articular cartilage, retinacular arteries form a 2nd ring -> subsynovial
intra-articular arterial ring -> lateral epiphyseal arterial branches enter head of
femur posterosuperiorly -> majority of superior weight bearing portion
4. Arteries of round ligament
• A branch of obturator or medial femoral circumflex artery
• Vessels in ligamentum teres (medial epiphyseal) unimportant
• Anastomoses with other arteries variable
• Femoral head circulation arises, therefore, from 3 sources
1. Intraosseous cervical vessels that cross marrow spaces from below
2. Artery of ligamentum teres
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ORTHOPAEDI UI
3. Retinacular vessels, chiefly
KINEMATICS
Range of motion
Motion Average range

Flexion 115
Extension 30
Abduction 50
Adduction 30
Internal rotation 45
External rotation 45
Instant centre analysis
• Cannot be performed accurately in hip by Reuleaux method as motion takes place in 3 planes
simultaneously
KINETICS
STATICS
Two leg stance
• During 2 leg stance, line of gravity of body passes behind pubic symphysis
• As hip joint a stable joint, no muscle forces required to maintain erect stance
• Force through each hip joint = ½ x (body weight - weight of legs)
Single leg stance
• W = force produced by body weight; M = force produced by abductors of hip; R = joint reaction
force
• Assume A, B & ø known,
• For equilibrium, sum of moments = 0
• W x B = My x A
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ORTHOPAEDI UI
• My = (W x B) / A
• Value for My is then found
• For equilibrium, sum of forces = 0 (in Y axis)
• My + W – Ry = 0
• Ry = My + W
• R can now be found by using Ry = R sinø
On using elbows & heels to get onto a bed pan unaided
• JRF at hip = 4x body weight

• Much reduced when using overhead trapeze
Using a walking stick how it reduces JRF
• Simplistically, in equilibrium sum of moments = 0
Without stick With stick
Ab x A = W x B (Ab x A) + (WS x C) = W x B
Ab = (W x B) / A Ab = [(W x B) – (WS x C)] / A
• So force required by abductors Ab smaller if a stick used

• The bigger C is, the smaller Ab, therefore a walking stick in hand furthest away from hip
most effective
• In equilibrium, sum of the forces in Y plane = 0
Without stick With stick
JRFsinø = Ab + W JRFsinø + WS = Ab + W
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ORTHOPAEDI UI
JRFsinø = Ab + W – WS
• Therefore JRF is less when a walking stick used

• Not only Ab force smaller, but upward force exerted by stick reduces JRF further
DYNAMICS
On walking
• Paul et al, using a force plate & kinematic data for normal hip found 2 peaks in joint reaction force
in hip
Proximal Femoral & Pelvic Osteotomies
Introduction
• Osteotomy realigns weight bearing surfaces of joint to allow normal areas to articulate, moving
abnormal area away from weight bearing axis
• Reduce point loading
• Improve congruity
• This can be achieved by either performing a proximal femoral osteotomy or pelvic osteotomy (or
both)
• Proximal femoral osteotomy increases blood flow to femoral head & neck & increases venous
drainage.
• Results
• For early disease results of 80-90% relief of pain
• Success rates = 70% over 11 yrs follow-up
• However, conversion to THR can be difficult due to alignment of femur & metalwork which can be
difficult to remove
Indications
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ORTHOPAEDI UI
• Young patients with advanced degenerative changes in whom THR is not wise
• Non-union of a femoral neck #
• Dysplasia (varus osteotomy)
• Post-Perthes hinge abduction (valgus extension osteotomy)
• SCFE (flexion osteotomy)
• AVN (flexion osteotomy)
• Idiopathic protrusio (valgus extension osteotomy)
Clinical
• Pain in certain hip positions only (eg. adduction WBing)

• Arc of movement - which part of arc is painful
• Leg lengths (effect of FFD)
Planning
• Considerations
• Best results in young, non obese patients with good ROM (minimum 90º flexion, 15º
abduction/adduction)
• Femoral osteotomy may distort anatomy which may jeopardise a future THR
• Clinical
• Position in which there is least pain & joint is congruent
• For varus osteotomy must have >15 abduction preop
o
• For valgus osteotomy must have >15 adduction preop

o
• Imaging
• AP & lateral X-rays are taken in adduction/abduction
• Berne or Faux profile view (WBing 25 profile) - shows anterior uncovering
o
• CT or MR can give additional information

• Need to determine
• Amount & direction of correction
• Choice of implant
Varus Osteotomy
• Generally indicated where lateral subluxation is a/w coxa valga
•
o
Must have >15 abduction preop
• Relaxes adductors, abductors & flexors
• Shortens leg
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ORTHOPAEDI UI
Valgus Osteotomy
• Indications
• Uncovered head made worse by abducting hip
• Deformed head with lateral osteophyte (post Perthes)
• Fixed adduction deformity
• Can add lateral displacement of greater trochanter to reduce hip joint reaction forces
•
o
Must have >15 adduction preop
• Contraindications
• Stiff
• Obese
• Gross narrowing with sclerosis & no normal joint surface
• Atrophic inflammatory features
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ORTHOPAEDI UI
Ganz Osteotomy
43
ORTHOPAEDI UI
Hip Arthrodesis
Introduction
• Fusion (ankylosis) can occur spontaneously

• Following childhood sepsis
• Following ORIF of acetabular # (secondary to heterotopic bone)
• In ankylosing spondylitis
• Unpopular & careful patient selection important as it leads to
• Increased stress on other hip & ipsilateral knee
• Oxygen consumption 32% greater than normal
• Average walking speed 84% of normal
Indication
• Young patient <40 yrs who are, or plan to be, in heavy labor occupation, with unilateral hip
disease (usually post-traumatic)
• Contra-lateral hip, both knees & spine must all be normal
Contraindication
• Absolute: active sepsis of hip; infection should be rendered inactive for 12/12 before arthrodesis
• Relative
• Severe degenerative changes in lumbosacral spine, contralateral hip, or ipsilateral knee
• Poor bone stock because of osteoporosis or iatrogenic causes, eg. proximal femoral
resection for tumor -> lower success rates & increased disability
44
ORTHOPAEDI UI
Optimal position
•
o
25 flexion
•
o
Neutral to 5 external rotation
•
o
Neutral to 5 adduction
• Avoid abduction (pelvic obliquity) & internal rotation
Technique
• Surgical technique important if later conversion to THR is desired

• Lateral plating -> trochanteric ostectomy to preserve abductor mechanism
• Anterior plating does not violate abductor mechanism
• AO cobra-head plate (Modified Schneider)
• Stable but disrupts abductors
• Technique
• Position
• Supine
• Skin incision
• Linear longitudinal midlateral incision along femoral diaphysis to a point 8
cm distal to tip of greater trochanter
• Dissection & exposure
• Open fascia lata
• Incise origin of vastus lateralis & reflect it off greater trochanteric flair &
linea aspera for a distance of 6 cm
• Identify anterior & posterior margins of gluteus medius
• Make a greater trochanteric ostectomy so that proximal fragment
includes insertion of gluteus medius & minimus
• Elevate hip abductors with greater trochanteric fragment & hold them
superiorly with 2 large Steinmann pins hammered into iliac wing
• Perform a superior hip capsulotomy
• Elevate periosteum of outer table of iliac wing superiorly to retracting
Steinmann pins, anteriorly to ASIS & AIIS, & posteriorly to sciatic notch
• Place 1 blunt Hohmann retractor in sciatic notch subperiosteally to
protect sciatic nerve & superior gluteal artery, & 1 anterior to iliopectineal
eminence
• Fusion
• Make a transverse innominate osteotomy between iliopectineal
eminence & sciatic notch at superior pole of acetabulum
• Remove a corresponding 0.5 cm wafer of bone from superior pole of
femoral head
• Remove any cartilage & sclerotic cortical bone from femoral head &
acetabulum
• Displace distal hemipelvic fragment & proximal femur medially 100% of
thickness of innominate bone
• Position hip in 25 of flexion, neutral internal & external rotation, & neutral
o
adduction & abduction

• Contour a 9-hole cobra plate & secure proximal portion to ilium with a 4.5
mm cortical screw
• Use an AO tensioner to apply compression force across hip joint to
ensure good bony apposition
• Then secure plate to lateral femur with 4.5 mm bicortical screws
• Insert 4.5 mm cortical screws in proximal plate, taking care to protect
neurovascular structures on inner table of pelvis
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ORTHOPAEDI UI
• Reattach greater trochanter with a 4.5 mm cortical screw & washer

• Pack any remaining corticocancellous bone around hip joint
• Close soft tissue in layers over drains
• Postop
• Ambulation with partial weight-bearing encouraged on 2nd or 3rd day
after surgery
• Partial weight-bearing with 2 crutches continued for 6/52
• Trans-articular sliding hip screw

• Lag screw is inserted across joint & just superior to dome of acetabulum
• Disadvantages
• Poor fixation (due to large lever arm & resulting torque on lever arm)
• Need for postop hip spica
• Some authors advocate supra-acetabular osteotomy or subtrochanteric osteotomy for improved
positioning
Complications
• Non-union
• Malunion
• OA of hip, spine, knee
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ORTHOPAEDI UI
• Instability of ipsilateral knee
Prognosis
• Sponseller et al JBJS 66A: 853-859, 1984

• 53 patients with hip arthrodesis at least 20 yrs previously (average 38 yrs)
• All are able to work
• 78% satisfied with arthrodesis
• 57% low back pain to some degree - onset ~20 yrs
• 45% have ipsilateral knee discomfort
• 17% pain in contra-lateral hip
• 13% required conversion to arthroplasty for relief of back/knee pain
• Revision to THR gives relief of back pain but not relief of knee pain
• Callaghan et al "Hip arthrodesis" JBJS 65A: 1328-1335, 1985
• 28 patients, arthrodesis 17-50 yrs (average 35 yrs) previously
• 60% had back pain - average time to onset 25 yrs post arthrodesis
• 60% had pain in ipsilateral knee - average time to onset 23 yrs post arthrodesis
• 25% had pain in contralateral hip - average time to onset 20 yrs post arthrodesis
• 6 patientts had undergone THR for back or knee pain - all had marked relief of back pain
& 1/2 had relief of knee pain
• Those with fusion in slight adduction have a better gait, less problems with back pain &
with knee pain than those fused in slight abduction
Osteonecrosis
Definition
• Death of bone (usually adjacent to a joint surface) from ischaemia

• Osteocytes will survive 12-48 hrs of ischaemia & marrow cells 6 hrs
Features
• Age 20-50 yrs (average 38 yrs)

• Slight male preponderance
• Most commonly involves femoral head, then in descending order, distal (medial) femoral condyle,
humeral head, talus & less commonly lunate, capitellum & metatarsal heads
• Bilateral in 50% of idiopathic cases, & 80% of steroid induced cases
• Insidious pain which starts initially with activity, then at rest & eventually at night
• Pain may be severe for 6-8/52 & then subside
• Mild symptoms & effusion usually persists
• Night pain may be early feature
• Pain may be present for many months before X-ray changes are manifest
• Earliest examination finding: decreased internal rotation
• 5% of THR performed as a result of OA secondary to AVN
Aetiology
• Idiopathic (40%)
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ORTHOPAEDI UI
• Arterial insufficiency
• #
• Dislocation
• Infection
• Arteriolar occlusion
• Sickle cell disease & other haemoglobinopathies
• Caisson disease in divers & compressed air workers (eg. miners)
• Vasculitis eg. SLE, irradiation
• Capillary occlusion
• Fatty infiltration due to steroids, alcohol & other drugs eg. chemotherapy
• Systemic steroid Rx (37%)
• >30 mg prednisolone for >30/7
• High alcohol intake (20%)
• >400 ml/week or cumulative dose of 150 litres (equivalent to 375 litres of
vodka!)
• Gaucher’s disease
• Hyperlipidaemia
• Venous occlusion
• Other
• Renal transplant patients (16% will develop ON)
• Pancreatitis
• Haematological malignancies eg. lymphomas, leukaemias
• Diabetes mellitus
• Endotoxin reactions
• Toxic shock
• Inflammatory bowel disease
• Brain/spinal surgery
• Anticoagulant deficiencies
• Nephrotic syndrome
Pathogenesis of ischemia (Theories)

1. Intraosseous Hypertension (Compartment Syndrome of Bone)
• Raised intraosseous pressures have been consistently found in cases of ON

• Blood flow through intraosseous compartment is inversely proportional to bone marrow pressure
therefore any condition which causes an increase in this pressure will produce a decrease in
blood flow to bone in that area with subsequent ischaemia & ON
2. Abnormal Extraosseous Blood Flow
• Superselective angiography of medial circumflex artery has been used for extensive study of
extraosseous femoral head blood flow in patients with osteonecrosis of femoral head
• Consistent loss of transcortical blood flow from superior retinacular arteries & alterations in
revascularization process in hips with radiographically & preradiographically defined
osteonecrosis have been demonstrated
• A mechanism of alteration of process of revascularization has been considered to be a
contributory feature of nonreversible osteonecrosis
3. Fat Embolism
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ORTHOPAEDI UI
• Fatty osteocytic necrosis is felt to progress to ischaemic degeneration of necrotic osteocytes &
adipocytes
• When volume of subchondral fat overload results in vascular stasis, local hypercoagulability,
endothelial damage, & subsequent intravascular coagulation
• In this situation, local mechanisms of repair are prevented
• Histologically observed phenomena include intraosseous thromboses & peripheral haemorrhages
• These phenomena were observed in animals with induced intravascular coagulopathy & in
children with disseminated intravascular coagulopathy & histological evidence of interosseous
thrombosis & osteonecrosis
4. Fat Cell Abnormalities
• Fat cell hypertrophy & fatty marrow overload have been demonstrated in animals as a consistent
consequence of high-dose corticosteroid exposure
• Histological changes consistent with necrosis were frequently identified & femoral head blood
flow was consistently diminished
• Use of lipid clearing agents was shown to consistently improve this alteration in blood flow
5. Intravascular coagulation
• Final common pathway

• Coagulopathy involves intraosseous microcirculation coagulation -> generalized venous
thrombosis & retrograde arterial occlusion
Pathology
• Pathological stages
1. Ischaemia/Necrosis
• Autolysis of osteocytes & necrotic marrow
2. Fragmentation/Resorption
• Inflammation with invasion of primitive mesenchymal tissue & capillaries
• Hyperaemia & revascularization -> bone resorption
• New bone layed down on dead trabeculae -> increased density
• Alternating areas of sclerosis & fibrosis -> fragmentation
• Trabeculae in dead bone may fracture in subchondral region
• Lysis of bone -> collapse
3. Reossification/resolution
4. Remodelling
• If repair/revascularization rapid -> head may maintain its shape
• Head may collapse -> further flattening/fragmentation
• Dead bone is structurally & radiologically indistinguishable from live bone
• At 2-4/7 there is loss of cellular detail in marrow
• Necrotic osteocytes may appear normal for weeks by light microscopy
• Empty lacunae late feature of bone death
• Absence of remodelling -> development of stress #
• See Pathology Slides
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ORTHOPAEDI UI
Investigations
X-ray
• Normal in stage 0 & I

• Osteopenia & sclerosis in stage II (Case Study)
• Subchondral collapse “crescent sign” in stage III
• Secondary OA in stage IV
MR scan
• Ischaemic marrow changes evident before bone changes apparent

• Earliest finding
• Look for focal lesion in anterosuperior portion of femoral head that is well demarcated but
inhomogeneous
• T1 images - decreased signal from ischaemic marrow/single bandlike area of low signal
intensity
• T2 images - a 2nd, high signal intensity, line can be found within the line seen on T1
images, believed to represent hypervascular granulation tissue (= “double line sign”)
• Roles
1. Diagnosis
• 100% sensitivity, 98% specificity
• Rarely AVN may be found on histology with a normal MRI
2. Outline area of involvement
3. Show revascularization front & provide objective evidence of changes in tissue in
response to Rx
4. Allows sequential evaluation of asymptomatic lesions that are not yet detectable on plain
radiographs
Shimizu et al. Prediction of collapse with MRI of AVN of femoral head. JBJS 76A 1994
o Where at least 1/4 of diameter of femoral head & at least 2/3 of major weight bearing
area involved - 74% had collapsed within 32/12
MR Staging (see below)
T1 image T2 image (Double line sign)
Bone scan
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ORTHOPAEDI UI
• Cold area may be only evident in early stages of disease (14-21/7) prior to revascularisation
• Usually increased uptake at time of study
• Increased uptake on both sides of joint suggests OA rather than AVN
• 75-80% sensitivity in precollapse stage
Single Photon Emission Computed Tomography (SPECT) scan
• SPECT imaging is a 3-dimensional isotope scanning technique

• Has been shown to be useful in analysis of bone graft healing & in identification of early
osteonecrosis
• Because of its ability to 3 dimensionally visualize bone reactivity, it is helpful in identifying area of
decreased activity (cold spot) within an area of increased activity
• This clinical picture can be seen in a very early stage of osteonecrosis
Staging
Ficat Staging (J Bone Joint Surg Br 1985 Jan;67(1):3-9 - Full Paper)
Stage Pain Findings X-ray Bone MR Treatment

scan scan
0 (Preclinical) None None Normal Normal Normal None

(FEB +ve)
I Minimal Decrease Normal Non- Early Core

(Preradiological d internal diagnosti change decompression
) rotation c s
II Moderate Decrease Osteopenia/ +ve +ve Core

d ROM sclerosis; decompression
head , strut graft
spherical
III Moderate/sever Decrease Flattened +ve +ve Strut graft,

e d ROM head/ THR
crescent
sign
IV Severe Pain Secondary +ve +ve THR

degenerativ
e changes
• Original Ficat & Arlet Classification, in 1968

• Did not include Stage 0
• Stage 1 was preradiographic & known as 'Silent Hip'
Steinberg et al (JBJS 77B: 34-41,1995)
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ORTHOPAEDI UI
• Same as above for stages 0-III

• Stage IV: Flattening of femoral head
• Stage V: Joint narrowing with or without acetabular involvement
• Stage VI: Advanced degenerative changes
• These stages are further divided into mild (A), moderate (B) or severe (C) [See diagram]
ARCO Staging
• 5-stage system proposed by ARCO (Association Research Classification Osseous)
Stage Finding Quantification (AP X-ray)
0 Histology only
Area Involved (from Steinberg):
• Minimal <15%
(+) Diagnostic test (+ve MR or • Moderate 15-30%
1 bone scan) • Extensive >30%
2 (+) X-ray: no collapse
Length of crescent & Dome depression:

(+) X-ray: collapse
• Minimal - <15% crescent or <2 mm depression
• Crescent • Moderate - 15-30% crescent or 2-4 mm depression
3 • Collapse • Extensive - >30% crescent or >4 mm depression
4 (+) X-ray: osteoarthritis
• Radiographic types of involvement of femoral head are based on quantitative relationships to

dome of acetabulum on AP radiograph
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ORTHOPAEDI UI
MRI Staging
Class T1 T2 Definition
A Bright Intermediate "Fat" signal
B Bright Bright "Blood" signal
C Intermediate Bright "Fluid" or "edema" signal
D Dark Dark "Fibrosis" signal
Natural History (Mont & Hungerford JBJS 77A: 459-474,1995)
• Meta analysis of 21 studies involving 819 hips, average follow-up 34/12, all treated non-
operatively (various protocols of weight bearing status)
• Rates of preservation of femoral head
• Stage 1: 35%
• Stage 2: 31%
• Stage 3: 13%
Treatment Modalities
• Potentially reversible early if corticosteroids or alcohol stopped

• Symptomatic Rx, weight loss & physio
1. Protective Weightbearing
• A relatively poor choice for most patients

• May be indicated in certain circumstances eg. patients with very limited disease or not fit enough
for surgery
• Start with non-weightbearing with progression to weightbearing as clinical symptoms & signs
demonstrate that hip is less irritable
• Radiographic & clinical follow-up at 6/52 intervals until pain has subsided
• Likely that protective weightbearing would take minimum of 3-6/12 to return patient to full
weightbearing status without walking aids
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ORTHOPAEDI UI
• Success 5-20% at 3-5 yrs follow-up

• Only 1 study in literature is based on randomisation of therapeutic options
• In that study, limitation of weightbearing was shown both clinically & radiographically to be
statistically less successful than core decompression in stabilising Ficat stage I & II hips
2. Core Decompression
• Goal: to remove a central core of bone from lesional area to effectively lower intraosseous
pressure
• Biopsy obtained can confirm disease histologically
• Patients remain non-weightbearing for 6/52 postop
• Substantial controversy as to effectiveness of this procedure
• Appears to be best suited for stage I & II in which pain relief & preservation of femoral head are
predictable (>70%)
• Meta-analysis of 24 studies involving 1206 hips treated with core decompression
• Rates of preservation of femoral head
Core decompression No Rx
Stage 1 84% 35%
Stage 2 65% 31%
Stage 3 47% 13%
•
• Stulberg et al (CORR 186: 137-153, 1991) Randomised prospective study, 55 hips in 36
patients
Good Results Core decompression No Rx
Stage 1 70% 20%
Stage 2 71% 0%
Stage 3 73% 10%
•
• Core decompression of 128 femoral heads in 90 patients with Ficat 1, 2 or 3 disease
Stage 5 yr 10 yr 15 yr No Further Surgery Needed
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ORTHOPAEDI UI
1 100% 96% 90% 88%
2 85% 74% 66% 72%
3 58% 35% 23% 26%
• Kaplan-Meier survival curves

• Despite good clinical results 56% of hips progressed at least 1 Ficat stage
• Core decompression with electrical stimulation results ~ same as core decompression
alone
• Conclusion: core decompression delays need for THR
3. Proximal Femoral Osteotomy [Femoral Osteotomies]
• Goal: preservation of femoral head by altering pattern of stress transfer in diseased head
• This procedure directly addresses mechanical aspects of osteonecrosis on femoral head
• May compromise later THR
• Varus osteotomy
• Attempts to shift most involved portion of head medially
• Likely to work best for those lesions that are less extensive laterally
• Success has been reported in 74% of stage 3 hips in 1 series
• Rotational osteotomy (Sugioka)
• Designed to shift diseased portion of head medially, inferiorly, & posteriorly
• Although it is a structurally more appropriate Rx, it is technically difficult
• This approach can be a/w substantial morbidity, & is best reserved for hips in which
subchondral collapse has occurred
• Reported success rates
Intact weight bearing area after transposition Success
>60% 100%
>36% 93%
21-35% 65%
<20% 29%
4. Strut Grafting (fibula/tibia/iliac crest)
• This procedure, either of Bonfiglio non-vascularized type or using vascularised grafting technique,
may also be used in Rx of radiographically apparent disease & in early collapse stage
• Bonfiglio technique has been applied for several decades & seems to be effective if graft is
placed carefully in subchondral region
• Cortical strut grafts eg. ilium, tibia, fibula placed into a core track in femoral neck
• Grafting through a cortical window in femoral neck
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ORTHOPAEDI UI
• Limitations of this technique may be in its inability to effectively alter stress-transfer patterns in
upper femoral regions
• Although early reports of vascularised grafting techniques encouraging, studies to date not
sufficient to support widespread application
5. Trapdoor Procedure
• Indicated for pre-collapse (Stage 2)

• Surgical procedure
• Anterolateral dislocation of femoral head to expose area of femoral head collapse
• Break in articular cartilage identified & opened like a trapdoor
• Necrotic bone under flap excavated & then removed if need be with a power burr to
expose bleeding bone
• Defect then filled with cancellous bone graft from patient's iliac crest & overpacked into
defect to prevent subsidence
• Flap then carefully repositioned & hip reduced & capsule repaired
• In light of early experience with this technique in which this was the only procedure
performed & subluxation of hip occurred, operation is now followed by acetabuloplasty
with or without varus femoral osteotomy
• Good results reported in 2 studies - Mont et al. JBJS 1998; Ko et al. J Pediatr. Orth. 1995
6. Vascularised Pedicle Flaps
• Quadratus femoris graft (Meters) - posterior

• Tensor Fascia Lata muscle - anterior
7. Electrical Stimulation
• Use of PEMF’s with external coils in a large multicentre study was successful for stage 1, 2, & 3
hips, irrespective of aetiology of condition
• Appears as effective as core decompression for stages 1 & 2, but more effective for stage 3 hips
• This relatively uncomplicated Rx offers great promise, but is awaiting final FDA approval before it
can become widely available
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ORTHOPAEDI UI
Advanced Stages
• Arthrodesis
• Young patient with unilateral disease eg. trauma
• Problem: 50-80% of cases bilateral
• Conclusion: best to manage conservatively until bad enough to perform THR
• THR
• Both uncemented & cemented total hip arthroplasty have been used in this population
• Reported success rates are below what appear to be expected from series in other
patient populations
References
• Ficat. J Bone Joint Surg Br 1985 Jan;67(1):3-9 - Full Paper
TOTAL HIP REPLACEMENT

Total Hip Replacement - Study Guide
The logic behind choosing different hip implants - NICE study

When to do a THR - alternatives
• Requirements for a successful osteotomy

• Acetabular osteotomy
• Femoral osteotomy
• Trapdoor procedure for AVN
Choosing a type of THR
• Composite beam & cement engagement type stems

• Torsional resistance
• Cemented vs uncemented
Acetabulum
• Dollar Bill: poor results with cemented acetabulae

• How to get good results with cemented acetabulum
• Preparation of reamer skirt
• Containment & bone graft
• Pressurisation
• Polyethylene - x link; aging; thickness; low frictional torque
• Types of uncemented - not as bone conserving as you might think
• Hemisphere; apatite
• Screws - safe zone; liner wear & snap fit; risk of backside wear
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ORTHOPAEDI UI
• Charnley zones
• Direction of wear vector
• Volumetric vs linear wear
Head
• Size - reasons for small & large

• Material - steel or ceramic
• Consequences of modularity
Stem
• 2 types
• Nature of loosening process
• Loosening & osteolysis
• Macrophages etc
• Wear: size of particles & source, third body wear
• Nature of scratches etc
• Gruen zones
• Proximal vs distal loading in femoral stems
• Detection of loosening
• Possible & definite loosening
• RSA how to institute a follow up system
• Which type of cement?
Which to choose - data
• Swedish studies
• Randomised studies
• RSA studies
Quality of surgery
• How many do you do each year?

• How good are your X-rays etc
Indications, Pre-operative Management & Surgical

Considerations
Indications
• Persistent symptoms of pain from hip with limited ambulation, night pain, severe quality of life
limitation despite conservative therapy
• Conservative options tried 1st: weight loss, NSAIDS, walking stick in contralateral hand
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ORTHOPAEDI UI
• Used in
• OA (primary or secondary)
• Inflammatory arthritis
• Osteonecrosis
• #
• Failed reconstructions
• Tumours
Contraindications
• Absolute
• Active infection
• Relative
• Preexisting medical problems which have not been optimised
• Skeletally immature
• Non ambulators
• Neurotrophic joint
• Abductor muscle loss
• Progressive neurological disease
Pre-operative Management
Preop assessment
• Indication & contraindications

• Ensure that pain is from hip, not referred from back etc
• Infection
• Dental evaluation
• Nasal & perineal swabs for MRSA
• FBC, U+Es, MSU
• Medical evaluation
• Medications
• Aspirin & other antiinflammatory drugs should be discontinued 7-10 days before surgery
• Anticoagulant should be discontinued in sufficient time for bleeding & clotting times to
return to normal
• Transfusion
• Preop Hb main indicator for need of postop transfusion
• Hb <11 g/dl strong indicator for need for transfusion
• Consider preop donation of blood, or GXM
• Autologous blood
• 2 units for primary hips or cell saver
• Disadvantages: time consuming, expensive, significant decrease in preop Hb
level (which actually increases likelihood of transfusion), possibility of clerical
error, possibility of transfusion reaction
• Erythropoitin
• Physical exam
• Previous incisions & soft tissues
• Strength of abductor musculature - Trendelenburg test
• Flexion, adduction, or abduction contracture, fusion of contralateral hip, or flexion
contracture of contralateral knee will place additional stresses on hip
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ORTHOPAEDI UI
• Limb length
• Vascular status
• Infections (eg. infected ingrown toenail, prostatitis, etc)
Preop planning
• X-rays
• Pelvis AP view centred at hip, with leg internally rotated to 15 (allows templating by
o
eliminating femoral anteversion)

• Lateral film
• Planning & templating
• Surgical approach
Explain, explain & explain...
• What you are going to do

• Benefits
• Complications
• What patient cannot do post-op & assess patient's expectations
• Do's & don'ts
Consent
• Informed consent to include

• Local risks
1. Leg length inequality possible (15%)
2. Dislocation - 3%
3. Infection - 2%
4. Loosening - at about 10-15 yrs
5. 1% of patients not satisfied
• Systemic risks
1. Urinary tract (& chest) infection - 10%
2. Clinical DVT - 2%
3. Non-fatal PE - 1%
4. Fatal PE - <0.5%
5. Mortality - <0.5%
Prevention of infection
• Shave at last minute

• Intravenous antibiotic, 1.5 g IV cefuroxime, to be continued for 24-48 hrs postop
• Wilson Aglietti & Salvati: reduction of infection from 11 to 1%
• Lidwell et al
• Reduction of infection to 0.1% with combination of clean air sytems, body exhaust suits &
antibiotics
• Antibiotics decreased risk of sepsis to greatest extent
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ORTHOPAEDI UI
Surgical Considerations
Surgical aims
• Primary stability
• Long term stability
• Minimise adverse effect to bone
• Restore hip biomechanics
• Minimise wear
Surgical approach
• Mainly a matter of personal preference & training

• Each approach has advantages & disadvantages
Surgical anatomy of superior gluteal nerve & ... direct lateral approach to hip
Bos JC. Stoeckart R et al. - Surgical & Radiologic Anatomy. 16(3):253-8, 1994
• In view of increasing popularity of direct lateral approach to hip joint for hemi- or total hip
arthroplasty, location of SGN was studied
• This nerve is in danger when using a transgluteal incision
• In 20 embalmed specimens, relation of SGN to tip of greater trochanter (TT) was studied as well
as relation to iliac crest
• For this purpose macroscopy, microscopy & CT were used
• In 13 hips a so-called most inferior branch was found at an average of 1 cm distal to inferior
branch, the main trunk of nerve
• There was substantial variation in course of both inferior & most inferior branch of SGN
• In order to prevent nerve damage, proximal extension of transgluteal incision should be limited to
3 cm cranial to TT
• Furthermore incision has to be confined to distal 1/3 of distance TT-iliac crest
• In tall people extra care should be taken
Charnley approach
• Trochanteric osteotomy
• Patient supine
• Slightly curved skin incision centred over greater trochanter beginning at level of anterior superior
iliac spine
• Fasci lata incised for whole length of incision
• Cholecystectomy forceps placed into joint & pushed from anterior to posterior
• Gigli saw used to perform trochanteric osteotomy, with or without a pin to create a chevron
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ORTHOPAEDI UI
• Trochanteric wiring or Dall miles cable grip to refix trochanter
Advantages according to its advocates Disadvantages according to its opponents

Easy to dislocate hip Increased blood loss
Good exposure of acetabulum Longer operating time
Less penetrations in reaming femoral canal Technical difficulty with fixation of trochanter
Cement can be inserted easily Nonunion of trochanter, causing trendelenburg
gait
Useful in primary THR when anatomy distorted Wire breakage
Better femoral component alignment Trochanteric bursitis
Can be used in primary & revision surgery
Hardinge direct lateral approach
• Patient supine or in lateral position
62
ORTHOPAEDI UI
• Slightly curved skin incision centred over greater trochanter

• Incise fascia lata for whole length of incision
• Incise gluteus medius from greater trochanter, leaving posterior 1/2 to 2/3 attached
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ORTHOPAEDI UI
• Split vastus lateralis distally & extend proximally through line of fibres of gluteus medius (not >3
cm to avoid superior gluteal nerve)
• Detach gluteus minimus from its insertion
• Expose capsule & open with a T shaped incision
• Closure can include sutures between bone & capsule through drill holes
• Main disadvantage: potential damage to superior gluteal nerve & damage to abductors
• Not always suitable for revision surgery
Dall variation of Hardinge approach
• Involves taking a sliver of bone of greater trochanter with muscle
Posterolateral approach (Moore or Southern)
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ORTHOPAEDI UI
• Patient in lateral position

• Slightly curved skin incision centred over posterior aspect of greater trochanter from level of ASIS
to 10 cm distal to greater trochanter
• Divide fascia lata in line with skin incision at level of greater trochanter
• Bluntly split gluteus maximus proximally in line of its fibres by blunt dissection
• Retract gluteus maximus & fascia lata to expose posterior aspect of hip with overlying external
rotators & sciatic nerve
• Internally rotate hip to put external rotators on stretch & place stay sutures into piriformis &
obturator internus
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ORTHOPAEDI UI
• Divide external rotators just before they insert into greater trochanter & fold them back over
sciatic nerve
• Quadratus femoris does not normally need to be divided
• Incise hip capsule with a longitudinal or T shaped incision
• Dislocate hip by internal rotation
Advantages (by advocates) Disadvantages (by opponents)

Avoids cutting abductors Increased risk of posterior dislocation ?
because of difficulty in orientation
Avoids Cx of trochanteric osteotomy Needs to be done in lateral position, so
anatomic orientation can be difficult
Can be used for primary & revision surgery
Anterolateral approach of Watson-Jones
• Exploits internervous plane between tensor fascia lata & gluteus medius (actually both supplied
by superior gluteal nerve but supply to TFL enters very high up)
• Patient supine
• 15 cm straight incision centred over tip of greater trochanter
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ORTHOPAEDI UI
• Divide fascia lata proximally heading anteriorly & distally along line of femur
• Dissect few fibres of glueus medius from anterior flap of fascia lata
• Locate interval between TFL & gluteus medius with fingers
• Retract gluteus medius & minimus & externally rotate hip to put capsule on stretch
• Incise origin of vastus lateralis along its insertion ridge
• Lift off fat pad overlying hip capsule
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ORTHOPAEDI UI
• Partial resection of gluteus medius tendon posteriorly
• Detach reflected head of rectus femoris from joint capsule to expose anterior rim of actebulum
(with hip flexed)
• H shaped incision in capsule
Choosing a THR Prosthesis
• Choice of prosthesis depends on

1. Prosthesis
2. Instrumentation
3. Surgical expertise & experience
Prosthesis
• Acetabulum
• Aim of acetabular component is to orientate THR as close to anatomical axis of rotation
as possible
• Cemented
• Ogee cup has proved to be most reliable
• Cement on socket does very well for about a decade, then, increasingly, more
loosening & higher incidence of re-operation (Harris)
• Uncemented designs: HAC threaded cups have proved better than oversized press-fit &
screw fixed cups
• Femoral component
• Cemented femoral stems have proved more reliable than uncemented
Surgical Expertise
• A number of studies, including hip registers (Swedish, Trent, Norwegian) have shown that
experience of surgeon correlates with less Cx
Summary
• Acetabular component
• Cemented all-PE > cemented metal-backed PE > cementless HAC > cementless
oversized press-fit & screw fixed
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ORTHOPAEDI UI
• Femoral component
• Cemented > cementless
Femoral Component
Stem
Features & biomechanics
• Definitions
• Stem length: from medial base of collar to tip of stem
• Vertical height: from medial base of collar to a horizontal line through center of head
• Head-stem offset: from center of head to line through axis of distal part of stem
• Neck length: from center of head to base of collar
• Angle of neck: by intersection of line through center of head & neck with another along
lateral border of distal half of stem
• Ideal femoral reconstruction reproduces normal center of rotation of femoral head, location of
which is determined by 3 factors
1. Vertical offset
2. Medial offset or, simply, offset
3. Version of femoral neck (anterior offset)
Vertical Offset
• Restoring vertical height essential to correcting leg length

• Determined by
• Primarily neck length & length gained by modular head
• Vertical position of stem - the depth the implant is inserted into femoral canal
• Level of femoral neck osteotomy in cemented stem
• Using a stem with variable neck lengths provides a simple means of adjusting this distance
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ORTHOPAEDI UI
Medial Offset
• Increasing offset
• Increased abductor lever arm
• Requires lower abductor muscle force to counteract moment of center of gravity -
> advantageous following surgery where abductor muscles are weakened by
underlying disease process & neuromuscular damage at surgery
• Reduces joint reaction force -> lower polyethylene wear
• Increased hip abduction motion
• Increased stresses within stem & cement mantle at distal tip of femoral component
• May lead to stem # or femoral loosening
• Roderick et al -> varying offset from 33 to 58 mm
• No significant increase in stress transfer or micromotion in cemented
THR
• Cementless femoral components - increasing offset results in 7x
increase in rotational micromotion
• Reduced offset in presence of weak abductors -> instability, bony impingement & increased joint
reaction forces
• Medial offset is primarily a function of stem design
• Medial offset is directly related to femoral neck length
• Where neck length has been increased, the greater the lever arm or moment of force that
tends to bend or break component, as well as increasing strain on medial cement mantle
• This led Charnley to reduce offset in his original designs
• Offsets may be altered in design & manufacturing stage or through surgical techniques at time of
insertion
• Charnley prosthesis has a fixed neck length, while some femoral components with
modular heads allow 8-12 mm of variability, which can be used to adjust vertical height &
offset
• At surgery offset may be altered by
1. Depth of implant insertion into femoral canal
2. Level of femoral neck osteotomy
3. Varus/valgus insertion of femoral component
This additional surgical flexibility is not available with cementless femoral component, since depth
& orientation of insertion is determined by fit within femoral metaphysis rather than by level of neck
osteotomy
Individual femoral components must be produced with a fixed neck-stem geometry that
determines offset
However, many components are now manufactured with both standard & enhanced offset
versions
o
This is accomplished by reducing neck-stem angle (typically to ~127 ), by attaching neck to stem
in a more medial position, or both
Version
• Refers to orientation of neck in reference to coronal plane

• Restoration of femoral neck version important in achieving stability of prosthetic joint
• Retroversion can result in posterior dislocation, especially when a posterior approach has
been used
• Anterior dislocation may occur with excessive anteversion of prosthetic neck
• Proper neck version usually accomplished by rotating component within femoral canal
• This presents no problem when cement is used for fixation
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ORTHOPAEDI UI
• However, when press-fit fixation is used, femoral component must be inserted in same orientation
as femoral neck to maximize fill of proximal femur & achieve rotational stability of implant
Orientation
• Femoral component should be neutral in both AP & lateral planes, but slight anteversion (5-10º)
well tolerated
Design
• Evolution of cemented stems

• Before Charnley
• Options
• Cheilectomy, arthrodesis, osteotomies
• Soft tissue interposition
• Artificial replacement eg. ivory ball
• Cup/mould arthroplasty (from glass to vitallium)
• Endoprosthesis
• Judet's brothers' - acrylic femoral head & stem (1946)
• Austin Moore - IM stem vitallium prosthesis, fenestrated, 3-point
fixation
• Thompson
• Charnley Era
• Charnley
• Early experiments with resurfacing double-cup, cementless, hybrid ->
fixation Cx
• Contributions
• Principles of low friction arthroplasty (LFA)
• Fixation with PMMA (1958)
• Ultra clean air in OT
• 1962
• Cemented high density polyethylene socket
• Cemented stem with head size 22.25 mm
• Early stem #
• 2%
• Due to cantilever bending (proximal bending on a distally fixed
stem)
• Attempted solutions
• Modified material to reduce corrosion & fatigue
• Flanged (flat-backed) stem to increase proximal loading
• Change offset to reduce bending moment
• Increase head:neck ratio
• Cementing technique: bone block for pressurisation
• HDPE -> UHMWPE
• MaKee & Watson-Farrar
• Chrome-cobalt metal socket
• High frictional resistance -> loosening
• Variations of Charnley stem
• Stanmore
• 25-mm head
• Muller
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ORTHOPAEDI UI
• 32-mm head, curved stem

• Exeter
• Collarless polished double-tapered stem in 1969
• Subsidence to engage cement beneficial
• Tight seal prevents distal passage of particulate matter
• Matte stem surface in 1976
• Aseptic loosening 10% at 10 yrs
• Abrasion damage to cement mantle
• North American
• Harris -> improved cementation
• Distal & proximal occlusion
• Gun
• Lavage
• Pressurisation
• Grit-blasted, precoating stems -> gross loosening & proximal osteolysis
• Lubinus
• After Charnley
• Cementless
• Peter Ring (1960) - press-fit femoral stem, concept of biologic
fixation
• Use of HA
• Ceramics
• Metal-on-metal
• 10-100x lower wear
• Self-polishing capacity
• C-stem
• Stem design
• Materials
• Stiff materials (Co-Cr, stainless steel) reduces cement stresses, are harder &
more corrosion resistant
• Geometry
• Shape
• Curved stem design
• Considered anatomic, because they fit to anatomic bow of
proximal femur
• Straight stem
• Surgeon machines curved bony anatomy to fit prosthesis
• Cross-section
• Canal-filling rectangular stems inherently stable with torsional loads even
in absence of cement
• Taper
• Allows controlled subsidence in polished stems
• 3rd taper -> loading of proximal & medial femur
• Decreased proximal femoral strain shielding
• Increased proximal femur bone remodeling
• No sharp corners
• Surface finish
• Rough
• Provides adhesion & mechanical interlock
• Abrasive damage to cement -> loosening
• Polished
• Allows subsidence
• Tight seal prevents transport of wear debris
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ORTHOPAEDI UI
• Offset
• Optimal offset improves abductor mechanics & prevent medial impingement
• Increased offset increases torsional load in non fit-&-fill stems
• Collar
• If a collar is seated on cut surface of neck or if a layer of cement is in contact with
bone & undersurface of collar -> axial loading of bone
• Stress transfer to femur provides physiologic stimulus for maintaining
bone mass & preventing disuse osteoporosis
• Thereby reduce stresses in proximal cement
• Collar also serves to determine depth of insertion of femoral component, since
vision is temporarily obscured by extrusion of cement
• Both collared & collarless stems have good long term results
• Cemented vs cementless
• Cemented stem
• Uncemented stem
• Proximal fixation
• Distal fixation
Materials
Stiffness (lowest to highest) Material Surface Hardness

Bone Titanium (Ti-6Al-4V) 330
Titanium (Ti-6Al-4V) Cobalt-chrome alloy 400
Stainless steel Nitrogen ion-implanted Ti-6Al-4V 770
Cobalt chrome Zirconia 1430
Ceramic
Surface finish
• Surface finish of cemented & cementless designs is discussed below

• Data from Swedish hip register -> significantly higher failure rates in stems with rough surface
finish compared to polished stems
• Change in Exeter stem from polished to matt finish -> much higher failure rate
• Coating stem with PMMA in order to increase bond between component & cement -> much
higher early failure rate
Cemented vs cementless
• Femoral components are of 3 general types

• Cemented
• Cementless
1. Cementless with porous surface for bone ingrowth
2. Cementless press-fit varieties
Cemented
• Probably remains gold standard for THR
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ORTHOPAEDI UI
• Indications
• Most indicated in older patients (>65 yrs)
• Patients not expected to achieve tight fit necessary for ingrowth
• "Stove pipe" type femur
• Previous #
• Previous osteotomy
• Poor bone quality eg. RA, osteoporosis, or Paget's disease
• Primary stability fixation
• Fill canal
• Cemented component design
• Cobalt-chromium alloy used in most stems -> generate less particulate debris than
titanium
• Prosthesis that is broader laterally than medially may help to diffuse compressive stress
medially
• Taper
• Allows controlled subsidence in polished stems
• 3rd taper -> loading of proximal & medial femur
• Decreased proximal femoral strain shielding
• Increased proximal femur bone remodeling
• Surface finish
• Controversy about how much bonding should occur between cement & femoral
stem
• Excessive bonding may transfer weight bearing stress to bone-cement
interface -> loosening
• In contrast, excessive motion between cement-metal interface ->
excessive osteolysis & rapid loosening
• Smooth surface may allow subsidence & thereby keeps cement in compressive
loading
• Matt finish allows some mechanical interlock with cement
• DW Howie et al. JBJS. Vol 80-B. No 4. July 1998 p 573. Loosening of matt and
polished cemented femoral stems
• 4/20 matt coated stems had been revised for aseptic loosening
• 0/20 polished stems had been revised (9 yr minimum follow up)
• DK Collis et al, JBJS (Am) 84:586-592 (2002)
• 244 consecutive THR with cemented femoral component performed by 1
surgeon
• 4 hips treated with grit-blasted stem had aseptic loosening with
substantial surrounding lysis & required revision
• Additional 2 hips in this group had radiographic evidence of substantial
lysis & were judged to have impending need for revision
• No hip treated with polished stem required revision, & only 1 had minimal
lysis
• Prosthesis should have relatively smooth surfaces, with no sharp edges, so that
sites of stress concentration are eliminated from both prosthesis & cement
• Outcomes
• JJ Callaghan MD et al (J Bone Joint Surg [Am] 82-A: 487-97, 2000)
• Charnley THA (with cement) with minimum 25 yr follow up
• Of 327 hips for which outcome was known after minimum of 25 yrs, 295 (90%)
had retained original implants until patient died or until most recent follow-up
examination
• Of 62 hips in patients who lived for at least 25 yrs after surgery, 48 (77%) had
retained original prosthesis
• The Good
• Tried & true
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ORTHOPAEDI UI
• Immediate fixation
• Forgiving
• Metal surface not exposed to bone -> less oncogenic
• The Bad
• Increased bone erosion & loosening
• Fixation decreased with time
• Increased risk of fat embolism
• Technically demanding
Cementless
• Rationale for cementless

• Widespread use of THR in late 1960s
• Mid-term to long-term results available in mid-1980s
• At 15 yrs
• 85% (Wroblewski et al 1986)
• 91% (McCoy et al 1988)
• 73% loosening (Cotterill et al 1982) at 11 yrs
• PMMA fixation - mechanical interlock
• Fixation decreased with time
• Interface fail - no remodeling
• Passage for particulate debris, increase effective joint space
• Osteolysis
• Loosening
• Biologic fixation - potential for long-lasting fixation
• Bone ingrowth or ongrowth
• Microfracture - remodeling
• Reduce opportunity for passage of particulate debris
• Indications
• Younger patients (<65 yrs)
• Good bone stock
• Hemophilia
• Sickle cell
• Renal diseases
• Relative contra-indications
• Not stem of choice for patients not expected to achieve tight fit necessary for ingrowth
• "Stove pipe" type femur
• Based on proximal canal flare index
Dorr A Champagne flute 10%
Dorr B Proportional 80%
Dorr C Stove pipe 10%
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ORTHOPAEDI UI
• Previous #
• Previous osteotomy
• Poor quality bone stock is more likely to undergo plastic deformation & to allow
subsidence of femoral component
• Success of cementless THR
• Mechanical factors
• Primary stability
• Achieved by
• Press-fit
• Bone prepared 1-2 mm undersize
• Bone expand with introduction of prosthesis will
generate hoop stresses
• Keep prosthesis in position
• Reduce micromotion
• Line-to-line fit
• Bone prepared same size as implant
• Require additional measures to secure
• Extensive porous coating
• Fin
• Screw
• Initial interface micromotion
• Micromotion >150 µm -> fibrous ingrowth
• Cortical bone seating/anchoring allows stable bone ingrowth
• Secondary stability
• Surface texture
• Porous-coated - ingrowth
• Grit-blasted - ongrowth
• Intimate contact with host bone
• Gap
• No ingrowth
• Reduced mechanical stability
• Passage of particulate debris
• Biological factors
• Host bone response to material, surface roughness, surface coating
• Maintenence - minimize adverse bone effect - stress shielding
• Stiffness
• Extent of coating
• Primary stability fixation
• Fit canal, not fill canal
• How
• Metaphyseal locking
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ORTHOPAEDI UI
• Primarily stabilized in metaphysis via fit of prosthesis to endosteal cavity

• Depend on geometry of proximal part of stem to ‘fill & fit’ proximal femur
• Relatively bulky proximal part
• Taper stem
• Diaphyseal locking
• Stabilizing prosthesis through fixation of distal stem with hard cortical

bone of femoral diaphysis
• Porous coated/fin/flute stem cut into diaphyseal cortex
• Long & cylindrical & straight stem
• Proximal cortical contact dictated by position of distal stem
• Taper wedge fixation - fit not fill
• New concept
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ORTHOPAEDI UI
•3-point fixation
• Proximal - medial cortex
• Mid-stem - laterally
• Distal - variable
• Promotes excellent rotational stability
• AVN avoided as endosteal blood supply is maintained
• Allow subsidence
• Less demanding fit
• Cementless component design
• Prosthesis should be minimally stiff & maximally stable
• Prosthesis should prevent migration of particles from articular surface to stem
• Stiffness of femoral stem
• High modulus material will increase stresses in stem & decrease stresses in
cement -> transfer of stress into distal stem -> stress shielding of proximal femur
-> bone resorption
• Lower modulus material can increase stress on proximal bone but might also
increase stress, & thus fatigue, on proximal cement -> loosening
• Cementless implants substantially stiffer than cemented -> proximal micromotion
smaller -> stress shielding greater -> bone atrophy of proximal femur
substantially greater
• To maintain bone stock, proximal stress transfer must be a prominent feature of
any cementless implant
• Coating
• Most important factor for initial success of cementless THR
• Reduces micromotion between implant & bone along entire length of implant
• Porous-coated surfaces
• Provides bone ingrowth fixation
• For bone ingrowth to occur
• Optimal pore size 50-350 µm (preferably 50-150 µm)
• Porosity should be 40-50%
• Increased porosity -> risk of surface shearing off
• Pore depth
• Gap must be within 50 µm
• Cortical bone seating allows stable bone ingrowth
• Extent of coating
• Controversial
• Huiskies et al
• Ideal load transfer situation in femur with cementless
stems in order to prevent proximal stress shielding is
transitional stress or graduated load transfer from
proximal to distal, with highest load transfer proximally
• Extensively coated stems
• Porous coating over proximal 80% but tip is smooth
• Disadvantages: lack of proximal load transfer -> stress
shielding at neck & bone resorption
• No clinical problems, but risk of osteolytic induced # of
proximal femur
• Proximally coated stems
• Rely on biological fixation proximally but with distal
mechanical fixation
• Disadvantage: not a complete seal between component
& bone -> free passage of particulate wear debris down
side of stem -> subsequent osteolysis
• Grit-blasted surfaces
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ORTHOPAEDI UI
• Provides bone ongrowth fixation

• Process textures metal surface with pressurized spray of aluminum oxide
grit or stainless-steel shot which creates irregular surface of 3-8 µm in
depth
• An increasing surface roughness is directly related to an increase in
interface shear strength
• Bone fixation occurs only on surface
• More extensive area of coating required to secure prosthesis
• Typically, entire prosthesis needs to be grit-blasted
• Hydroxyapatie coating (More details)
• An adjuvant surface coating on porous-coated & grit-blasted surfaces
• An osteoconductive agent that allows for more rapid closure of gap
• Plasma spray technique
• Thicknesss
• Mechanical properties inversely proportional to its thickness with
thicker HA coatings having decreased toughness & fatigue
resistance
• HA thickness of 50-75 µm optimal (15 µm of HA is lost in 1st yr)
• Porosity of HA coating should be 150-400 µm for optimal ingrowth
• HA coatings allows maximal interface shear strength to be reached in
half the time compared to porous surfaces without HA coating
• Factors governing osteoconductive potential include ability to achieve
static fit with bone to minimise movement & gap size at HA/bone
interface
• When correct conditions met, surface ingrowth occurs to 60-80% of
available surface of femoral stems
• Attachment to bone is greatest with cortical bone & unpredictable with
cancellous bone
• If micromovement at HA/bone interface >50 µm -> fibrous tissue forms
instead of bone
• Complications
• Unpredictable fixation
• Thigh pain
• Osteolysis
• Stress shielding
• Femoral #
• Difficult extraction
• Metal surface in direct contact with bone
Head
Head size
• Small head (22 mm)

• Advantage: low frictional torque (R1 vs R2 ) thus reducing turning moment on
acetabulum
• Disadvantages: higher risk of dislocation & greater linear wear & creep
• Large head (32 mm)
• Advantage: theoretically greater stability & ROM
• Disadvantages: greater volumetric wear
• Optimal size for head
• Choice seems to have settled on 26 or 28 mm
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ORTHOPAEDI UI
• Minimizes penetration & volumetric wear (Livermore et al)

• Less acetabular strain & lower revision rates
Third body wear
• Predominantly arises from barium or zirconium particles released from cement

• These substances are added to cement to make it radio-opaque
• Cement (PMMA) itself does not cause 3rd body wear
Acetabular Component
Biomechanics
• Abduction angle
• Normal acetabulum is inclined from transverse plane at an angle of ~55
o
• Optimal position for prosthetic socket should be inclined ~45 to maximize stability of joint
o
• Centre of rotation of hip

• Restoration of normal hip center in acetabular reconstruction encourages restoration of
normal biomechanics
• Medial placement
• Medialisation of COR improves efficiency of hip abductors & will reduce forces
acting on hip in coronal plane
• In OA, acetabular osteophytes push femoral head laterally, superiorly, &
posteriorly
• To re-establish optimal hip mechanics, hip center must be placed medially,
inferiorly, & anteriorly
• Lateral placement
• Creates increased joint reactive forces
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ORTHOPAEDI UI
• Leads to uncoverage of superior acetabular cup (or inappropriate abduction of

cup to achieve coverage)
• Anterior placement
• Will reduce sagittal plane resultant forces about hip & improves efficiency of hip
extensor muscles
• Superior placement
• Requires use of long neck prosthesis to restore abductor moment arm
• May slightly improve efficiency of extensor muscles but may have more
significant -ve effect on hip abductors
Cemented acetabular components
• Despite improvements in component designs & cement technique, long-term survivorship has not
substantially improved
Charnley Ogee cup
• All polyethylene component

• Minimum thickness of 8 mm of polyethylene necessary to prevent wear
• Features
• External grooves
• Must be of sufficient depth & width to interlock with cement
• In general, grooves should be rectangular or dovetailed & profiled to
ensure strong mechanical interlock
• PMMA spacers, typically 3 mm in height, ensure uniform cement mantle
• Flange improves cement compression
• Beveling component at its mouth may allow better stability of femoral head while
avoiding impingement
• Metal-backed polyethylene component
• Introduced during 1980s
• Provides more uniform distribution of stresses to cement & pelvic bone
• In absence of metal backing, minimum thickness of 8 mm of polyethylene necessary for
comparable stress transfer
• Polyethylene is thinner than non-metal backed components
• Bartel et al predicted high stresses within polyethylene with thickness <5 mm ->
wear -> risk for premature failure
• Therefore, to maintain sufficient thickness of polyethylene, small head size must
be used with acetabular component that has small outer diameter
• Polyethylene is mechanically interlocked to metal shell
• Fixation to cement through interdigitation of cement with metal plasma spray coating
fused to exterior of shell
• Clinical results have not demonstrated measurably improved fixation with these metal-
backed devices
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ORTHOPAEDI UI
• 1 study -> results of a particular metal-backed acetabular component were inferior to that
of an all polyethylene design when both were cemented
• Indications
• Elderly, low-demand patients
• Bone ingrowth into a porous surface unlikely, eg. revision arthroplasty in which extensive
bone grafting has been necessary
• Some tumor reconstructions
Cementless acetabular components
• In USA, trend toward cementless fixation of acetabular components in younger, active patients
• Most cementless systems feature a metal shell with outside diameter of 40-75 mm with a modular
polyethylene liner
• Fixation
• Cementless acetabular components should be portions of spheres so that spherical
reaming will optimize contact
• Most are porous coated over entire circumference for bone ingrowth
• They differ in means of initial stabilization
• Fixation of porous shell with transacetabular screws
• Risk to intrapelvic vessels & viscera
• Requires flexible instruments
• Press-fit
• Other devices have enlarged peripheral rim that can be press-fitted onto
bone, generating hoop stresses
• Sufficient initial fixation a requirement for osseointegration & secondary
stability of press fit cups
• Normal bone ingrowth
• Generally for bone ingrowth to occur
• Component must lie within 50 µm of acetabulum
• Micromotion of prosthesis must be kept below 150 µm (preferably 50-
100), otherwise, only fibrous ingrowth
• Sufficient initial fixation
• Cortical bone seating
• Allows stable bone ingrowth
• Cancellous bone -> bone ingrowth, but mechanical strength of
an implant seated onto cortical bone is much stronger
• Important to achieve good cortical rim fit of acetabular cup
• RD Bloebaum et al, 1997
• Bone ingrowth into component averages only 12%, even though 84% of
cup surface was in contact with periprosthetic bone
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ORTHOPAEDI UI
• Bone ingrowth found to be uniform in all zones, most likely due to

uniform distribution of stresses from metal backing
• Role of polyethylene
• Another important design consideration is congruence of inner surface of metal shell to
outer surface of UHMWPE liner
• Inadequate congruence -> excessive stress & # of UHMWPE or, alternatively, motion &
wear between components
• Titanium may be inappropriate bearing surface against polyethylene
Wear of acetabulum
• Polyethylene cups removed from patients after up to 14 yrs of use -> area of greatest wear is in
o
superior part of socket in line with 10-15 inclination toward midline where body weight is applied
to femoral head
• Wear also may be seen in rim of Charnley cups, caused by impingement of neck of femoral
component
• Occasional deformation seen in posterior part of socket, usually by recurrent
subluxation/dislocation rather than neck impingement
• Thicker polyethylene -> less stress transmitted to bone & wider dissipation of stress in bone ->
less loosening
Polymethylmethacrylate Cement (PMMA)

How it works in arthroplasty
• Allows secure fixation of implant to bone

• Its success in doing so depends on how it is used
• No adhesive properties -> not a glue
• No chemical bond to bone or to surface of metal components
• It is a space-filling, load-transferring material or ‘grout’
• Mechanical bonding to cancellous bone
• Produced by forcing cement into interstices
• Important that this bonding is strong to minimise movement at cement-bone interface
which
• Can produce poor load transfer
• Can generate & distribute wear debris
• Mechanical bond between cement & implant
• Can be achieved if implant surface is textured or porous
• Though this reduces survival clinically
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ORTHOPAEDI UI
Mechanical properties
• Brittle, therefore notch sensitive, best not to be used with implants with sharp corners
• Stronger in compression than in tension & shear
• Viscoelastic
• Fatigue strength ~20-25% of single cycle strength
Composition
• Polymer
• Supplied as
1. Powder Polymer
• Packet of powder containing
• Particles of PMMA
• 10% radiopaque barium sulphate (or sometimes zirconium
dioxide)
• A polymerisation initiator (1% of benzoyl peroxide)
2. Liquid Monomer
• Vial of liquid containing
• Methylmethacrylate monomer
• An activator (~3% of DMP toluidine) that promotes cold curing
process
• Also a trace of retardant to minimise monomer polymerisation
during storage
• Other additives
1. Antibiotics
Only heat stable antibiotics in powder form can be used eg. Gentamycin,
Tobramycin, Erythromycin, Vancomycin, Cephalosporin
Palacos has best results for leeching of contained antibiotic
2. Colourant - methylene blue or chlorophyll, to allow easier differentiation from
bone during revision
Mixing
• Depending on manufacturer, liquid is added to powder or vice versa

• Modern mixing with vacuum of 500 mmHg can reduce porosity of cement from 9-27% to as low
as 1%
• Centrifugation also reduces porosity of cement produced
• Porosity reduction improves fatigue properties of cement
Curing
• Polymerisation process that occurs when dry & liquid components are combined
• This forms long-chain polymers that are essentially linear & relatively free of cross linking
• Curing process may be characterised by following time periods
• Dough time
• Starts from beginning of mixing & ends at point when cement mixture will not
stick to unpowdered surgical gloves
• ~2-3 min for most PMMA cements
• Working time
• Time from end of dough time until cement is too stiff to manipulate
• Usually 5-8 min
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ORTHOPAEDI UI
• Setting time
• Period from beginning of mixture until surface temperature of dough mass is one-
half its maximum value
• = sum of dough time & working time
• Typically 8-10 min
• Polymerisation process - exothermic chemical reaction that liberates 12-14
kcal/100 g of typical bone cement
• Factors affecting curing of PMMA

1. More rapid mixing shortens dough time
2. Increases in room temperature shorten both dough & setting times by 5%/degree
centigrade & vice versa
3. Increased humidity decreases setting time
Cementing technique
Technique
st
1 generation 1. Finger packing
2. No canal preparation
nd
2 generation 1. Cement gun to allow retrograde filling (1971)
(1975)
2. Pulsatile lavage
3. Canal preparation (brush & dry)

4. Cement restrictor
Has improved femoral revision rates

No effect on acetabular side
rd nd
3 generation As for 2 generation +
(1982)
1. Pressurisation of cement after insertion
2. Cement porosity reduction (vacuum or centrifugation)

3. Surface changes to implant to improve implant cement bonding (roughening or texturing, or
precoating to form a chemical bond found to be detrimental)
4. More recently, use of stem centralizer to ensure uniformity of cement mantle
nd
Still awaiting proof that this is an improvement on 2 generation
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ORTHOPAEDI UI
Grading of cement technique

Barrack et. al. JBJS 1992 and Mulroy et.al. 1995
• Grade A: medullary canal completely filled with cement (white out)

• Grade B: slight radiolucency exists at bone cement interface
• Grade C: radiolucency of >50% at bone cement interface
• Grade D: radiolucency involving >100% of bone cement interface in any projection, including
absence of cement distal to stem tip
• As noted by Mulroy et.al. 1995, a femoral cement mantle <1 mm & defects in cement mantle a/w
early loosening
Factors affecting bone cement strength
Factors which can’t be changed Effects

by surgeon
Aging of cement after implantation Gradual 10% loss of strength due to chemical changes
Environmental temperature 10% weaker at body temp than at room temp
Moisture content Weaker by 3-10% than dry cement
Factors partially controlled by
surgeon
Cement thickness Optimum thickness between 2-5 mm
If too thick, stress protection can occur in surrounding bone
If too thin, cement can fracture
For femur, use two-thirds rule: 2/3 of canal displaced by stem, 1/3
by cement
Constraint The more constrained the cement is, the more likely it is that
compression is the resultant force rather than tension or shear
Inclusion of blood or tissue Can decrease strength by up to 70% depending on amount
Stress risers (sharp edges in Cement is notch sensitive
implant)
Factors which can be controlled
by surgeon
Antibiotic inclusion Leads to 5-10% loss of strength
Centrifugation/vacuum mixing Leads to increased strength by 10-25%
Insertion pressurisation Reduces porosity therefore increases strength
Mixing speed If mixing too fast or too slow, strength loss can be up to 21%
Radiopaque fillers Can reduce strength by 5%
Problems with PMMA
• Cement reaction
• Hypotension can occur on pressurisation of cement into femur
• This is due to monomer leakage -> peripheral vasodilatation & direct myocardial
depression
• Transient hypotension does not correlate with level of monomer in circulation but with
deficit in blood volume
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ORTHOPAEDI UI
• Fat & bone emboli or air emboli have been reported

• Pulsatile lavage may help to prevent embolization phenomena, by removing fat & marrow
from canal
• In older co-morbid patients, consider avoiding pressurization of cement, since risk of
acute embolization may be higher than late loosening
• Local tissue effects of PMMA
•
o
Heat of polymerisation may exceed coagulation temperature of tissue proteins (67 )
• Occlusion of nutrient metaphyseal vessels may produce bone necrosis
• Cytotoxic & lipolytic effects of nonpolymerised monomer
• Willert et al -> following histological progression
1st 3/52 A layer of soft tissue & fibrin up to 3 mm becomes necrotic as do larger foci of
postop cancellous bone
3/52 to 2 yrs A period of repair
Bed of implant undergoes ingrowth of fibrous tissue & capillaries replacing necrotic
bone
After 2 yrs Bed of implant well established
Thin membrane of connective tissue of 0.5-1.5 mm thick
Spaces containing round fragments of cement have surrounding giant cell response
Brand of cement used
• In 1998 Swedish Hip Register, Palacos with or without Gentamycin & Simplex led to less revision
than with CMW
• Worst results with Sulphix cement
• Boneloc cement led to catastrophic failure due to loosening; supposed to reduce monomer
leakage & have reduced temperature of exothermic reaction
Postoperative Management of THR
Postoperative Radiographic Evaluation

Leg length & offset
• Leg length discrepancy

• Measured by noting relative positions of lesser trochanters from a line drawn tangential to
ischium
• Ranawat (Orthopedics 1999) -> 87% of patients had leg lengths within 5 mm of each
other
• Note that with an increased offset femoral component, gluteus medius may be tight ->
pelvic tilt -> apparent leg length inequality
• As gluteus medius stretches out over several months, apparent leg length inequality
decreases toward normal
• Offset
• Horizontal & vertical offset depends on
1. Amount of acetabular reaming
2. Femoral neck cut
3. Modular components in both acetabular cup & femoral stem
• Easiest way to judge offset is to compare Shenton's line of opposite hip
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ORTHOPAEDI UI
• A break in Shenton's line along with decreased area under curve indicate decreased
offset
Radiology of acetabular component
• Note that plain radiographs may be more accurate for identifying femoral component loosening
than for acetabular loosening
• Radiographic evaluation of cup position
• Judet views
• Cross table lateral: for evaluation of position of acetabular component (anteversion) &
status of posterior bone stock in posterior column & neck of ilium
• Lowenstein lateral radiograph
• Provides lateral view of acetabular subchondral bone & cup after implantation
• Modified Lowenstein lateral radiograph is similar to oblique radiograph of pelvis
• Patient is turned onto affected hip at least 45° & as much as necessary to allow
lower limb to be in abduction & external rotation & to be flat on X-ray table
• Polyethylene wear (need to rule out osteolysis with annual radiographs)
• Acetabular component loosening
• Whereas patients with loose femoral components often c/o pain, patients with loose
acetabular components may be asymptomatic
• Asymptomatic patients with radiographic evidence of loosening need to be followed for
implant migration & loss of bone stock
• Some surgeons will recommend revision for radiographic loosening even if patients have
no symptoms
Radiology of femoral component
• Postop AP & lateral X-rays should include entire length of stem & cement mass
• Yearly radiographs for progressive osteolysis
• Radiographic views
• Frog leg lateral: gives best lateral of proximal portion of femoral component
• Stress views: may detect implant loosening
• Weight bearing & non weight bearing views
• Push pull views
• Implant migration (indicates loosening)
• Pistoning/subsidence
• Medial midstem pivot
• Calcar pivot (distal toggle)
• Bending cantilever (distal pivot)
• Cemented femoral component
• Femur & cement column inspected carefully & compared with previous films for changes
indicating component loosening, stem failure, trochanteric problems, or infection
• Uncemented femoral component
• End of stem pain usually present from time of surgery, tends to improve during 1st yr, but
may remain constant thereafter
• Although bone scans may help, many noncemented THR, esp. long stems, may show
some increase in activity
• Divergent radiolucent lines in area of ingrowth indicate loosening
• Varus/valgus positioning
• Traditionally, varus positioning thought to lead to premature loosening
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• Sochart & Porter 1997 -> neither varus or valgus stem position appeared to be a/w
premature stem loosening (average 20 yrs follow up)
Rehab
• Rehab program will speed recovery of motion & function, diminish limp, & aid in return to
independent living
• Preop
• Patient motivated & informed of appropriate goals
• Transfers, use of supportive devices, how to negotiate steps, dislocation precautions,
anticipated schedule for recuperation & hospital discharge
• Immediate postop
• Triangular pillow to maintain ~15 of abduction & prevent extremes of flexion
o
• Postop day 1
• Bed exercises & limited mobilization
• Deep breathing, ankle pumps, quadriceps & gluteal isometrics, & gentle rotation
exercises
• Straight leg raising not helpful
• Drains removed 24-48 hrs after surgery
• Postop day 2
• Sit on side of bed or in a chair in a semirecumbent position
• Prevent excessive flexion, adduction & internal rotation
• Gait training -> walker for balance & stability
• Amount of weight-bearing allowed depends on means of fixation of components,
presence of structural bone grafts, stress risers in femur, & trochanteric osteotomy
• Cemented: early weight-bearing to tolerance permitted
• Cementless: porous ingrowth implants -> limited weight-bearing for 6-8/52
• Hip extension exercises encouraged, especially preexisting flexion deformity
• Discharge
• When able to get in & out of bed independently, walk over level surfaces, & climb a few
steps
• Printed instructions reviewing home exercise program & precautions to prevent
dislocation
• 1st 6/52 after surgery, use elevated toilet seat & 1 or 2 ordinary pillows between knees
when lying on unoperated side
• Showering allowed when wound healing satisfactory
• Sexual activity can be resumed in supine position
• Outpatient clinic 6/52 after surgery
• X-rays
• Uncomplicated primary arthroplasty, crutches can be discontinued
• If structural bone grafting or revision, crutches can be continued for 3/12 or longer
• Strengthening exercises for abductor muscles will help eliminate limp
• Stretching exercises continued until patient is able to reach foot for dressing & nail care
• Return to work
• Sedentary occupations: after 6-8/52
• Occupations requiring limited lifting & bending: after 3/12
• Return to manual labor not recommended
• Limited athletic activity permitted
• Swimming, cycling, golfing acceptable
• Jogging, racquet sports, other activities requiring repetitive impact loading or extremes of
positioning of hip unwise
• Follow-up at 3/12, 6/12 & 1 yr & periodically thereafter
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ORTHOPAEDI UI
• Routine X-rays at 1-2-yr intervals for signs of

• Loosening
• Migration
• Wear
• Implant failure
Complications of THR
Local
Intraoperative
Nerve Injuries
Vascular Injuries
Haemorrhage & Haematomas
Perioperative
Infection
Postoperative LDP SawLimBeng
Limb Length Discrepancy

Dislocation
Periprosthetic Fractures
Stem Failure & Acetabular Wear
Loosening & Osteolysis
Trochanteric Non-union & Migration
Heterotopic Ossification
Systemic
Urinary Tract Complications

Thromboembolism
Others
Nerve Injuries
• Incidence of sciatic & femoral nerve palsies

• 0.7-3.5% in primary THR
• 7.5% in revision THR
• Using EMG, >75% incidence of subclinical injury to superior & inferior gluteal innervated
muscles with both posterior & lateral approaches
• Other nerves injured - pudendal & common peroneal nerve
• Risk factors
1. Revision procedures
2. Female gender
3. THR for DDH
4. Significant lengthening of extremity
Causes
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ORTHOPAEDI UI
o Retraction (femoral, sciatic, gluteal)

o Iatrogenic direct trauma (any)
o Thermal or pressure injury from extruded cement (femoral, sciatic)
o Subgluteal hematoma formation (sciatic)
o Excessive lengthening causing stretching of nerve (sciatic)
o Postop positioning with abduction pillow (common peroneal)
Nercessian, Gonzalez & Stinchfield
o Somatosensory evoked potential (SSEP) to monitor sciatic nerve during revision
procedures
o Neurological compromise noted in 32% of patients, primarily caused by excessive
retraction during exposure of posterior aspect of acetabulum or by extremes of
positioning of extremity for femoral cement removal
Vascular Injuries
• Rare (0.2-0.3%)
• Most vascular injuries have been reported to occur during revision surgery
• Femoral artery & vein most common from retraction & dissection over front of acetabulum
• Removal of soft tissue & bone from inferior aspect of acetabulum may produce bleeding from
obturator vessels
• Penetration of medial wall of acetabulum by reamer or intrusion of cement into pelvis may injure
common iliac artery or superficial iliac vein; these vessels usually are separated from medial
cortex of pelvis by iliopsoas muscle, but in some this muscle is thin
• Late vascular problems: thrombosis of iliac vessels, arteriovenous fistula, false aneurysms
• Common sources of venous & arterial bleeding

• Branches of obturator vessels may be cut when ligamentum teres, transverse ligament &
bone are removed from inferior aspect of acetabulum
• Vessels near attachment of gluteus maximus tendon to femur that are part of cruciate
anastomosis
• Medial circumflex vessels distal to attachment of psoas tendon to lesser trochanter
• Branches of femoral vessels near anterior capsule
• Branches of inferior & superior gluteal vessels
Infection
Limb Length Discrepancy
• Love & Wright reported 18% of patients had lengthening of >1.5 cm

• Possible effects
1. Patient dissatisfaction
2. Lengthening >2.5 cm can cause sciatic nerve palsy
3. Vaulting type gait pattern
4. Low back pain (?)
5. Increased joint reaction force & premature mechanical failure have not been linked to leg
length discrepancy
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Dislocation
Periprosthetic Fractures
Stem Failure & Acetabular Wear
Loosening & Osteolysis
Trochanteric Non-union & Migration
Heterotopic Ossification
Urinary Tract Complications
• Bladder infection
• Most common Cx
• 7-14% after total hip arthroplasty
• In patients with urinary obstruction caused by prostatic enlargement, transurethral
resection should be advised before hip surgery; otherwise risk of postop retention &
subsequent infection high
• In patients who develop postop urinary obstruction, prostatic surgery is delayed if
possible for 6/52 or more to avoid early bacterial seeding of hip, & during this interval
patient should receive antibiotics
• Bladder injuries - rare
• Acute renal failure - rare
Thromboembolism
Others
• Fat embolism syndrome - fat particles & bone marrow forced into circulation at time of femoral
preparation & stem insertion have been reported to produce right atrial turbulence, bradycardia, &
increased quantities of fat particles in cardiac & femoral vein blood samples
• Gastrointestinal
1. Bleeding gastric ulcer may be caused by stress reaction
2. Acute cholecystitis
3. Postop ileus usually is neurogenic & lasts for only a short period, but when persistent,
could be a result of intrapelvic extrusion of cement
• Myocardial infarction & congestive heart failure
• Mortality - 1.2%
Hip Dislocations & Fracture Dislocations

Mechanism of Injury
• Almost always due to high energy trauma, eg. MVA, fall from a height, or industrial injury
• Force transmission to hip joint occurs with application to 1 of 3 common sources
1. Anterior surface of flexed knee striking an object
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ORTHOPAEDI UI
2. Sole of foot, with ipsilateral knee extended

3. Greater trochanter
• Direction of dislocation - anterior vs posterior - determined by direction of pathologic force &
position of lower extremity at time of injury
Anterior
• 10-15% of hip dislocations

• Degree of hip flexion determines whether a superior or inferior type of anterior hip dislocation
results
• Inferior (obturator) dislocation due to simultaneous abduction, external rotation, & hip
flexion
• Superior (iliac or pubic) dislocation due to simultaneous abduction, external rotation, &
hip extension
• Limb externally rotated & abducted & slightly flexed
• Rx
• Closed reduction - multiple attempts not advisable
• Allis maneuver
• Patient supine
• Assistant stabilises pelvis
• Knee flexed
• Surgeon applies in-line traction
• While increasing traction force, surgeon should slowly increase degree of
o
flexion to ~70
• Gentle rotational motions of hip & slight adduction will often help femoral
head clear lip of acetabulum
• A lateral force to proximal thigh by assistant may assist in reduction
• If CR unsuccessful perform open reduction via anterior approach
• Cx
• Neurovascular compromise - direct pressure on femoral artery, vein or nerve
• AVN less than in posterior dislocation ~8% of cases
• Posttraumatic arthritis develops in 30%
Posterior
• 80% of hip dislocations

• Dashboard injury
• Neutral/adduction at time of injury -> simple dislocation only
• Abduction at time of injury -> posterior acetabular wall #
• Adduction at time of injury -> femoral head #
• Limb internally rotated & adducted & flexed
• Cx
• Associated knee ligament injuries especially PCL, posterolateral complex
• Sciatic nerve injury 10-14%
• Superior gluteal artery injury
• Femoral head #
• 10% of posterior hip dislocations a/w femoral head #
• Almost all femoral head # a/w hip dislocations
• AVN
• Posttraumatic arthritis
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ORTHOPAEDI UI
Radiology
• X-rays
• AP of pelvis
• Femoral heads should appear similar in size, & joint spaces should be symmetric
throughout
• Posterior dislocations, femoral head will appear smaller than normal
head
• Anterior dislocation, head will appear slightly larger
• Shenton's line
• Relative appearance of greater & lesser trochanters may indicate pathologic
internal or external rotation of hip
• Adducted or abducted position of femoral shaft should also be noted
• Rule out femoral neck # before any manipulative reduction
• Cross-table lateral view may help distinguish a posterior from an anterior dislocation
• Judet views
• May help to ascertain presence of osteochondral fragments, integrity of
acetabulum, & congruence of joint spaces
• Femoral head depressions & # may also be seen
• CT scan
• Usually obtained after successful CR
• If CR not possible & open reduction planned -> CT to assess femoral head, presence of
possible intraarticular fragments, congruence of femoral head & acetabulum & to rule out
associated femoral head & acetabular #
• MRI
• ? role
• Integrity of labrum & vascularity of femoral head
Classification
Thompson & Epstein of Posterior Hip Dislocations
Type I Dislocation with or without minor #
Type II Dislocation with a large single # of posterior acetabular rim
Type III Dislocation with comminution of posterior acetabular rim with or without a major fragment
Type IV Dislocation with # of acetabular floor
Type V Dislocation with # of femoral head
Pipkin (subclassification of Epstein-Thompson type V)
Type I Posterior dislocation of hip with # of femoral head distal to fovea
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ORTHOPAEDI UI
centralis
Type II Posterior dislocation of hip with # of femoral head proximal to fovea

centralis
Type III Type I or II posterior dislocation with associated # of femoral neck
Type IV Type I, II, or III posterior dislocation with associated # of acetabulum
Treatment
• Acute phase
• ATLS protocol
• Reduction
• Should be expedient to decrease risk of AVN of femoral head
• Should be ASAP
• Long-term prognosis worsens significantly if reduction (closed or open)
delayed >12 hrs
• See prognosis below
• Subacute phase
• Treat associated acetabular or femoral head #
Reduction
• Closed reduction
• Contraindication: ipsilateral femoral neck #
• 3 popular methods
Allis Method
• Patient supine
• Assistant stabilises pelvis
• Knee flexed
• Surgeon applies in-line traction
• While increasing traction force, surgeon should slowly increase degree of
o
flexion to 90
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ORTHOPAEDI UI
• Gentle rotational motions of hip & slight adduction will often help femoral
head clear lip of acetabulum
• A lateral force to proximal thigh by assistant may assist in reduction
• Stimson Gravity Technique
• Bigelow & Reverse Bigelow Maneuvers
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ORTHOPAEDI UI
• One attempt at CR - if unsuccessful -> open reduction

• Post CR
Check hip stability while patient still sedated or under anesthesia
• Flex hip to 90 in neutral position
o
• A strong posteriorly directed force is then applied

• If any sensation of subluxation detected -> additional diagnostic studies
& possibly surgical exploration or traction
• If an obvious large, displaced acetabular #, stability examination need
not be performed
Postreduction radiographs to confirm adequate concentric reduction
Postreduction CT evaluation for femoral head # or acetabular #, & osteochondral
loose fragments
Protected WB 2-4/52 if hip stable without associated injuries
Skeletal traction with a tibial pin if hip unstable
Open reduction
Indications
Dislocation irreducible by closed means
Nonconcentric reduction
# of acetabulum or femoral head that requires either excision or RIF
Ipsilateral femoral neck #
Approaches
Posterior (Kocher-Langenbeck) will allow exploration of sciatic nerve, removal of
posteriorly incarcerated fragments, Rx of major posterior labral disruptions or
instability, & repair of posterior acetabular #
Anterior (Smith-Peterson) recommended for isolated femoral head #
Anterolateral (Watson-Jones) useful for most anterior dislocations & for
combined # of both femoral head & neck
Direct lateral (Hardinge) will allow exposure anteriorly & posteriorly through same
incision
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ORTHOPAEDI UI
Post-op
No correlation between early weight bearing & AVN -> partial weight bearing
If reduction concentric & stable -> short period of bedrest -> protected weight
bearing for 4-6/52
If reduction concentric but unstable -> skeletal traction for 6-8/52 for acetabular #
to heal -> progressive protective weight bearing
Specific types
Type
1 If CR unsuccessful -> open reduction via posterior approach
Type
2 ORIF of posterior fragment
Type
3 ORIF if comminuted fragments render joint unstable or incongruous
Type Treat as for acetabular #

4 Postreduction traction 6-8/52
Type
5
Pipkin CR - no need to ORIF fragment

1 If not anatomical, fragment can be excised
Pipkin CR - risk of further #

2 If not anatomical, ORIF with small cancellous screws or Herbert screws
Pipkin Young patients: emergent ORIF of neck #, then treat head # using anterolateral (W-J) approach
3 Older patients with badly displaced femoral neck #: prosthetic replacement
Pipkin
4 ORIF of acetabular #, then ORIF of femoral head # even if nondisplaced, to allow early motion
Prognosis
• Excellent function can be expected, provided that neither AVN nor posttraumatic arthritis develop
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ORTHOPAEDI UI
Study Time AVN rate OA
Epstein 23.2%
CR 35%
OR with removal of all osteochondral fragments 17%
<6 hrs 4%
Hougaard & Thomsen >6 hrs 58% 25%
Brav <12 hrs 18%
(262 dislocations & #-dislocations) >12 hrs 57%
Stewart & Milford
(128 dislocations & #-dislocations) >24 hrs No good results
• Cx
• Posttraumatic arthritis
• Most common long-term Cx
• Incidence dramatically higher when a/w acetabular #, transchondral # or AVN of
femoral head
• AVN
• 15% of injuries
• Rate depends on
• Time to reduction (>6 to 24 hrs)
• Initial injury
• Protected weight bearing has no effect on development of AVN
• May develop up to 3 yrs post injury
• Recurrent dislocation
• Rare (<2%)
• Heterotopic ossification
• Occurs in 2% after dislocation or #-dislocation of hip, especially when open
reduction has been necessary
• But usually not disabling
• Infection
• Neurovascular injury
• Sciatic nerve injury 8-20% (peroneal division)
• Thromboembolism
Central Fractures & Fracture Dislocations
• Treat as for acetabular #
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PAEDIATRIC HIP FRACTURES
• Delbet's classification
• I - Transepiphyseal # (with & without dislocation of femoral head from acetabulum)
• II - Transcervical # (displaced & nondisplaced)
• III - Cervicotrochanteric # (displaced & nondisplaced)
• IV - Intertrochanteric #
• Rx
• Closed reduction & internal fixation
• If fails then open reduction
Knee Anatomy
MUSCLES
• Pes Anserinus
• Includes sartorius, gracilis & semitendinosus (Say Grace before Tea)
• Sartorius - very broad insertion, forming a sheath over gracilis & semitendinosus
• Gracilis - smaller & anterior to semitendinosus
• Semitendinosus - enveloping muscle belly extending more distally
• Functions - flexor of knee & internal rotator of tibia
• Iliotibial Tract
• Inserts into Gerdy's tubercle on tibia & extends to form lateral patellar retinaculum
• Also attaches to lateral femoral condyle forming a static lateral restraint
• Function - since it crosses centre of rotation of knee moving from flexion to extension it
acts as flexor in flexion & extensor in extension
• Biceps Femoris
• Multiple insertions
• 3 layers
1. Superficial layer - superficial to LCL
2. Middle layer - surrounds LCL
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3. Deep layer - attaches to head of fibula & Gerdy's tubercle on tibia

• Function - flex knee & externally rotate tibia
• Popliteus
• Forms floor of popliteal fossa
• Muscle attached to posterior tibia
• Tendon passes intraarticularly deep to femoral attachment of LCL to attach to femur
• Functions
Flex & internally rotate tibia when leg is free OR externally rotate femur on tibia
when tibia is fixed
Dynamic reinforcement of PCL, preventing posterior displacement of tibia on
femur
Semimembranosus
5 distal attachments
0. Oblique popliteal ligament - broad oblique expansion; tightens posterior capsule
1. Posteromedial capsule - semiM fuses with posterior capsule to form posterior
oblique ligament (static stabiliser & resists anteromedial rotation)
2. Deep head - anterior expansion deep to MCL
3. Direct head - direct attachment to post medial tibial condyle; palpable with knee
flexed
4. Anterior expansion - superficial fascial expansion coursing over fascia in leg
KNEE STABILISERS (Anatomical)
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• Medial (Warren & Marshall)
• Layer 1
• Sartorius
• Crural fascia - envelopes sartorius & gastrocnemius; distally joins periosteum of
tibia at insertion of sartorius
• Layer 2
• Superficial MCL parallel fibres (femoral condyle proximally, combines with layer 1
distally)
• Posterior oblique ligament
• Semimembranosus
• Layer 3
• Deep MCL
• True capsule
• Extends from articular margins of femur & tibia
• Firm attachment to medial meniscus -> comprising meniscofemoral &
meniscotibial portions = Coronary ligament
• Merges posteriorly with layer 2 -> posterior oblique ligament
• Lateral (Seebacher)
• Layer 1
• Iliotibial tract anteriorly
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• Superficial portion of biceps posteriorly

• Fascia
• Layer 2
• Retinaculum anteriorly
• Patello-femoral ligaments posteriorly
• Layer 3
• Arcuate ligament
• Fabellofibular ligament
• Joint capsule
• LCL (lateral epicondyle to fibular head)
• Medial Collateral Ligament

• Superficial & deep fibres
• Superficial MCL
• Deep to gracilis & semitendinosus tendon
• Femoral insertion: medial femoral condyle
• Tibial insertion: periosteum of proximal tibia deep to pes anserinus
• Anterior fibres tighten during 1st 90 of motion
o
• Posterior fibres tighten in extension

• Deep MCL
• Capsular thickening that blends with superficial fibres & attaches to medial
meniscus (coronary ligaments)
• Lateral Collateral Ligament
• Cord-like structure
• Femoral insertion: lateral femoral epicondyle posterior & superior to insertion of popliteus
tendon
• Tibial insertion: lateral aspect of fibular head
• Located behind axis of knee rotation
• Tight in extension
• Lax in flexion
• Posterolateral Complex
1. Arcuate ligament
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• Y shaped condensation of fibers that courses from fibular head, over popliteus
• When fabella is large, there is no arcuate ligament & fabellofibular ligament is
robust
2. Lateral collateral ligament (LCL)
3. Popliteus tendon
4. Popliteofibular ligament
• Fibers originate from popliteal tendon & insert onto fibula
• Deep to arcuate ligament & its fibers orientation are opposite from arcuate
ligament
5. Reinforced by biceps, popliteus, & lateral head of gastrocnemius
Arcuate Complex
0. LCL
1. Arcuate ligament
2. Popliteus
3. (Gastrocnemius)
4. (Biceps)
Posterior Capsule
• Formed mainly by oblique popliteal ligament - reflected portion of semimembranosus

tendon
INTRA-ARTICULAR STRUCTURES
• Anterior Cruciate Ligament
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ORTHOPAEDI UI
• Completely intraarticular with synovial membrane envelope

• Tibial insertion: broad, irregular, oval area just anterior to & between intercondylar
eminences
• Femoral insertion: semicircular area on posteromedial aspect of lateral femoral condyle
• ~33 mm long, 11 mm in diameter
• 2 bundles
• Anteromedial fibres - tight in flexion - limits anterior translation of tibia on femur
• Posterolateral fibres - tight in extension - limits anterior translation PLUS external
rotation
• Blood supply - middle genicular artery (post) & synovial vessels (ant)
• Receives innervation from tibal nerve
• Mechanoceptors with a proprioceptive role
• Mechanics
o Made up of multiple collagen fascicles: 90% type I collagen, 10% type III
o ACL strength = 50% PCL strength
o Load to failure = 1700 N
o Strain rate plays a role in location of ligament failure
Midsubstance tears occurring at higher rates
Bone ligament complex tears occurring at lower rates
o No fibres are truly isometric but anteromedial fibres have least variation in length (~1.5
mm)
o Most taut in extension
o Primary function
To prevent anterior displacement of tibia on femur
To control rotation of knee
• Posterior Cruciate Ligament

• Origin
• Anterolateral aspect of medial femoral condyle in area of intercondylar notch
• Much more anterior than that of ACL
• Insertion: tibial attachment not intra-articular, but over back of tibial plateau, ~1 cm distal
to joint line
• Size: 13 mm, length: 38 mm (approximates that of ACL)
• Orientated vertically
• Subdivisions
• Anterolateral bundle
• Represents ~95% of substance of PCL
• Tight in flexion
• Most surgeons seek to reconstruction anterolateral portion noting its
larger size & more important functional role
• Posteromedial bundle
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• 5% of PCL
• Tight in extension
• Blends with posterior horn of lateral meniscus
• Posterior menisco-femoral ligament of Wrisberg extends from posterior horn of
lateral meniscus to femur behind PCL
• Anterior menisco-femoral ligament of Humphrey, if present, passes in front of
PCL
• Major blood supply: middle genicular artery
• Nerve supply: tibial nerve (significant mechanoreceptors)
• Mechanics
• Provides 95% of total restraining force to posterior translation of tibia on femur &
prevents hyperextension
• Secondary constraints include posterolateral complex & MCL
• 2x as strong as ACL
1. Larger cross-sectional area
2. Higher tensile strength
3. Located closer to central axis of knee joint
Meniscii
Fibrocartilagenous
Shape
Crescent shaped; triangular in cross-section
Lateral meniscus more circular; medial meniscus more C-shaped
Attachments
Anterior horn of lateral meniscus & posterior horns of both meniscii attach to intercondylar
eminence
Anterior horns attached to each other by small transverse anterior intermeniscal ligament
Attached peripherally via coronary ligaments
Popliteus muscle attached to lateral meniscus (not tendon)
Semimembranosus attached to medial meniscus
Lateral meniscus has twice excursion of medial meniscus during knee motion
Blood supply
From branches of lateral, middle & medial genicular arteries
Vascular synovial tissue from capsule supplies
Peripheral 20-30% of medial meniscus
Peripheral 10-25% of lateral meniscus
Frontal section of medial compartment demonstrates microvasculature of medial meniscus.
Perimeniscal capillary plexus (PCP) permeates through peripheral border of meniscus. F: Femur; T: Tibia.
[Arnoczky SP, Warren RF. Microvasculature of human meniscus. Am J Sports Med. 1982;10:90-95]
• Constituents
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1. Type 1 collagen fibres arranged radially & longitudinally (circumferential)

Longitudinal fibres - dissipate hoop stresses in meniscus
Radial fibres & longitudinal fibres - allows meniscii to expand under compressive
force
2. Proteoglycans
Trapped within collagen fibres to absorb energy
• Mechanics
• Circumferential fibers act in much same way as metal hoops placed around a pressurized
wooden barrel
• Tension in hoops keeps wooden staves in place
• Compression of menisci by tibia & femur generates outward forces that push meniscus
out from between bones
• Circumferential tension in menisci counteracts this radial force
• These hoop forces are transmitted to tibia through strong anterior & posterior
attachments of menisci
• This hoop tension is lost when a single radial cut or tear extends to capsular margin &
that in terms of load-bearing, a single radial cut through meniscus is equivalent to
meniscectomy
• Following total menisectomy there is decrease in tibiofemoral contact area & increase in contact
stresses
• With only 1/3 of meniscus removed, as with partial meniscectomy, ~65% increase in
articular contact stress
• Total meniscectomy may increase peak loads up to 235%
• In ACL-deficient knee menisci, specifically posterior margins aid in stabilising knee from anterior
translation
NERVE SUPPLY
• Motor
• Femoral n.
• All 4 Quad muscles & sartorius
• Obturator n.
• Gracilis
• Tibial Component of Sciatic n

• Semitendinosis, Semirnembranosis, & long head of Biceps
• Common Peroneal Component of Sciatic n
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• Short head of Biceps

• Sensory
• Saphenous nerve
• Largest cutaneous branch of femoral nerve
• Supplies sensation to skin over anteromedial aspect of leg
• Main terminal branch, sartorial nerve, runs distally with greater saphenous vein
• Infrapatellar branch of saphenous n. arises proximal to knee joint, around or through
sartorius, & then crosses underneath patella to innervate skin over proximal anterior tibia
• Free nerve endings are more prominent in peripheral portions of menisci & help to
transmit pain
• Mechanoreceptors have been identified in anterior & posterior horns
• Cruciate ligaments receive nerve fibers from posterior articular branches of tibial nerve ->
may serve some type of proprioceptive & sensory
Knee Ligament Injuries

Bony parts of knee joint inherently unstable & abnormal shifts prevented mainly by ligaments & muscles
• Definitions
• Instability: abnormal increased range of motion due to ligamentous, capsular, meniscal,
cartilage or bone injury/abnormality
• Strain: stretching injury to a musculotendinous attachment to bone
• Sprain: injury limited to ligaments (connective tissue attaching bone to bone)
Classification of knee joint instability resulting from ligament injury

I. One-plane instability (simple or straight)
• One plane medial

• One plane lateral
• One plane posterior
• One plane anterior
II. Rotary instability
• Anteromedial
• Anterolateral
• In flexion
• Approaching extension
• Posterolateral
• Posteromedial
III. Combined instability
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ORTHOPAEDI UI
• Anterolateral-anteromedial rotary
• Anterolateral-posterolateral rotary
• Anteromedial-posteromedial rotary
Classifications of Ligament Injury/Laxity Testing
• O'Donaghue, 1973
1st Degree Sprain Ligament injury with no instability

2nd Degree Sprain Partial tear with some laxity
3rd Degree Sprain Complete tear with marked instability
• Noyes
Grade 1 0-5 mm
Grade 2 6-10 mm
Grade 3 11-15 mm
Grade 4 16-20 mm
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ORTHOPAEDI UI
PATELLA
• Largest sesamoid bone (usually 3-5 cm in length) & lies within quadriceps tendon
• Ossification center usually appears at 2-3 yrs of age, but may be as late as 6 yrs
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ORTHOPAEDI UI
• Anomalies of ossification usually related to an accessory ossification center located at

superolateral corner of patella -> bipartite patella
• Triangular with apex directed distally
• Proximal patellar pole broad & thick & receives insertion of rectus femoris & vastus muscles
• Medial & lateral margins receive fibers from vastus medialis & lateralis, respectively
• Distal pole or apex provides origin of patellar tendon
• Thin layer of quadriceps tendon a/w thick Sharpey's fibers passes over anterior surface of patella,
joining patellar tendon distally
• Posterior 3/4 covered by articular cartilage & divided into major medial & lateral facets that
articulate with anterior trochlea of distal femur
• Blood supply by extraosseus anastomotic ring within loose connective tissue lying over extensor
mechanism
• Vessels contribute to this anastomotic ring: central superior geniculate vessel, medial & lateral
superior & inferior geniculate vessels, & inferior recurrent tibia vessel
• Primary blood supply enters bone through middle of anterior portion of body & is directed mainly
upwards, & through distal pole vessels
• Incidence of AVN ranges from 3.5-24%
• More often after internal stabilization of # treated with circumferential repair that occludes
peripatellar blood supply
• Patella tendon to patella length usually ratio of 1:1 (+/- 20%)
• 10% of patients have complete suprapatella membranes & 75% will have at least 1 of 3 plica's
even if only as a remnant (suprapatella, medial patella or infrapatella)
• Function
1. Increased mechanical advantage of quadriceps
2. Aid articular cartilage nourishment of femoral condyles
3. Provide some protection of femoral condyles
• Normal function depends on alignment, stability, articular cartilage & muscle control
• Also see Patellofemoral Instability
Primary Restraints Secondary Restraints
1. Iliotibial band: 24%

2. Mid medial capsule: 22%
Anterior 3. Mid lateral capsule: 20%
ACL 85%
translation 4. MCL: 16%
5. LCL: 12%
6. Meniscii
PCL 95% (large anterior bundle more NB

Posterior o LCL
translation progressively from 0 to 90 )
o
ACL POL/PMC has secondary effect within 0-45
Internal rotation
Popliteofibular ligament
External LCL & posterolateral complex - mainly at 30o POL/PMC
rotation
flexion
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ORTHOPAEDI UI
MCL - at all degrees of flexion
Superficial MCL - primary restraint to valgus

stress at all angles (least effect at full
extension) Posterior Oblique ligament (POL) - especially
Postero-Medial Capsule - tightened at full near or at full extension
Valgus
extension; past 30o it slackens ACL
Deep MCL (medial capsular ligament) - little
resistance to valgus load
LCL - in all positions of flexion Posterolateral structures (Popliteofibular lig.)

Varus o
Greatest effect at 30 , least at full extension ACL
KNEE MECHANICS
KNEE RESTRAINTS
• Primary role of ligaments of knee: to provide passive restraint to abnormal motion
Posterolateral Structures
• Arcuate ligament
• Fibular collateral ligament
• Popliteus tendon
• Popliteofibular ligament
• Fibers originate from popliteal tendon & insert onto fibula
• Deep to arcuate ligament & its fibers orientation are opposite from arcuate ligament
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ORTHOPAEDI UI
KINEMATICS
Instant Center of Rotation
• "If one rigid body rotates about another rigid body, its motion at any instant can be described by a
point or axis of rotation called instant center of rotation (ICOR)" (Simon, AAOS Basic Science
1994)
• Method developed by Reuleaux in 1876
Surface Joint Motion
• Motion between tibia & femur -> both rotational & translational
• Femoral condyles both roll & glide as they articulate with tibial plateaus
• 4-bar cruciate linkage system
• Describes motion of knee joint & interplay of ligaments
• Centre of joint rotation = intersection of cruciate ligamnets
• As knee moves from full extension into flexion, ICOR moves posteriorly relative to both femur &
tibia
Screw Home Mechanism
• During normal gait pattern tibia undergoes internal rotation during swing phase & external rotation
during stance phase
• External rotation of tibia on femur occurs during terminal degrees of knee extension, because of
difference in radius of curvature of medial & smaller lateral condyle
• This screw home mechanism in terminal extension results in tightening of both cruciate ligaments
& locks knee such that tibia is in position of maximal stability with respect to femur
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Patellofemoral Joint
• Primary function of extensor mechanism of knee -> deceleration during swing phase of gait
• Functions
• Increases moment arm of quadriceps
• Allows wider distribution of compressive stress between patellar tendon & femur
• From full extension to full flexion patella glides caudally 7 cm on femoral condyles
•
o
By 20 of knee flexion patella first begins to articulate with trochlear groove
•
o
Beyond 90 patella rotates externally & only medial facet articulates
• At extreme flexion patella lies in intercondylar groove
• Initially patella contact occurs distally & with increased flexion contact areas shift proximally on
patella
• Patellofemoral contact pressure 0.5x body weight with walking, & increases to 2.5-3.3x body
weight with stair climbing & descending
Meniscal Injuries
Anatomy
• Fibrocartilagenous
• Shape
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ORTHOPAEDI UI
• Crescent shaped; triangular in cross-section

• Lateral meniscus more circular; medial meniscus more C-shaped
• Attachments
• Anterior horn of lateral meniscus & posterior horns of both meniscii attach to
intercondylar eminence
• Anterior horns attached to each other by small transverse anterior intermeniscal ligament
• Attached peripherally via coronary ligaments
• Popliteus muscle attached to lateral meniscus (not tendon)
• Semimembranosus attached to medial meniscus
• Lateral meniscus has twice excursion of medial meniscus during knee motion
• Blood supply
• From branches of lateral, middle & medial genicular arteries
• Vascular synovial tissue from capsule supplies
• Peripheral 20-30% of medial meniscus
• Peripheral 10-25% of lateral meniscus
• Frontal section of medial compartment demonstrates microvasculature of medial
meniscus. Perimeniscal capillary plexus (PCP) permeates through peripheral border of
meniscus. F: Femur; T: Tibia. [Arnoczky SP, Warren RF. Microvasculature of human
meniscus. Am J Sports Med. 1982;10:90-95]
• Constituents
1. Type 1 collagen fibres arranged radially & longitudinally (circumferential)
Longitudinal fibres - dissipate hoop stresses in meniscus
Radial fibres & longitudinal fibres - allows meniscii to expand under compressive
force
2. Proteoglycans
Trapped within collagen fibres to absorb energy
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• Mechanics
• Circumferential fibers act in much same way as metal hoops placed around a pressurized
wooden barrel
• Tension in hoops keeps wooden staves in place
• Compression of menisci by tibia & femur generates outward forces that push meniscus
out from between bones
• Circumferential tension in menisci counteracts this radial force
• These hoop forces are transmitted to tibia through strong anterior & posterior
attachments of menisci
• This hoop tension is lost when a single radial cut or tear extends to capsular margin &
that in terms of load-bearing, a single radial cut through meniscus is equivalent to
meniscectomy
• Following total menisectomy there is decrease in tibiofemoral contact area & increase in contact
stresses
• With only 1/3 of meniscus removed, as with partial meniscectomy, ~65% increase in
articular contact stress
• Total meniscectomy may increase peak loads up to 235%
• In ACL-deficient knee menisci, specifically posterior margins aid in stabilising knee from anterior
translation
Functions
• Load bearing
• At least 50% of compressive load of knee joint transmitted through meniscus in
extension, & ~85% in 90° flexion
• In meniscectomised knee contact area is reduced ~50%
• Partial meniscectomy also increases contact pressures
• Shock absorption
• Menisci may attenuate intermittent shock waves generated by impulse loading during gait
• Shock absorbing capacity of normal knees ~20% higher than in meniscectomised knees
• Ability of a system to absorb shock has been implicated in development of OA (Radin &
Rose " The role of subchondral bone in the initiation and progression of Osteoarthritis"
CORR 213:34-40, 1986)
• Knee joint stability
• Meniscectomy alone may not seriously affect stability
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ORTHOPAEDI UI
• However, when a/w ACL tears, meniscectomy increases anterior laxity of knee
• Lubrication
• Proprioception
• This has been inferred from finding of type 1 & type 2 nerve endings in anterior &
posterior horns of menisci
Meniscal tears
Incidence
• 50% of knee injury that require surgery

• Medial meniscus tears 3x more often than lateral & tend to involve posterior horn
• Meniscal tears are uncommon in persons <10 yrs of age, but become increasingly common
during & after adolescence
Causes
• Meniscal tears can be either traumatic or degenerative in nature

• Traumatic tears
• Common in young patients
• Sports-related injuries
• More peripherally located
• May be a/w ACL injuries
• Degenerative tears
• Can be found in as much as 60% of population >65
• Majority of these tears, however, are asymptomatic & occur in association with
degenerative joint disease
• Commonly complex, irreparable tears
• Changing patterns of meniscal injury with chronological age most likely correlate with normal
alterations in collagen fiber orientation with aging, as well as increasing intrasubstance
degeneration
Classifications
• Location
• Red-red zone
• Red-white zone
• White-white zone
• Partial or full thickness tears
• Stable or unstable tears
• An unstable tear
• One where entire tear or a portion thereof can be displaced into joint space
• There it may become trapped, causing pain by traction at meniscocapsular
junction
• It may be responsible for symptoms of catching, locking, & effusion
• Tear patterns
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ORTHOPAEDI UI
/
Dandy (1990) looked at 1000 meniscal injuries ->70% were medial with a slight increase in the average age (39 years compared to 30 years
for lateral meniscus injuries)
Occur only when weight is being taken, in the young the knee is flexed and there is a twisting strain, in older patients tears may result from
minor force
The torn portion may be displaced into the joint ->locking
Clinical
• Usually fit & young

• Acute history of injury usually with localised pain +/- locking (a locked knee will flex but not extend
fully, history of unlocking is characteristic of a mechanical block)
• Symptoms may settle but -> repeated episodes
• Local signs will depend on time when joint is examined & whether or not it is still locked (usually
o
locked in 10-20 flexion)
• Medial or lateral joint line tenderness & clicking with knee rotation in full flexion -> pain
(McMurray's test)
• Special Tests for Meniscal Tears
Investigation
• (Arthrogram)
• MRI
• Mackenzie et al. Clin Radiol. 1996
• Multicentre review of 2000 patients
• Sensitivity 93%
• Specificity 84%
• Lateral meniscus - lower sensitivity 76%
• Post-meniscectomy - <25% accuracy if meniscus has been resected, 25-75% if
not resected
• Myxoid degeneration of posterior 1/3 of medial meniscus
• High signal intensity & commonly reported as a tear
• But if signal of 'tear' = fluid signal -> more likely to be a tear
• Meniscofemoral ligament can resemble a tear of anterior or posterior horns
• 60% of people >60 yrs have complete meniscal tears
• Intrasubstance tears common >40 yrs
• Tear definition = must extend to articular margin on 3 consecutive slices
• Problems of MRI - high cost, high false -ve rate
• Elvenes et al. Arch Orthop Trauma Surg 2000
• 'On basis of high predictive value of -ve MRI, MRI is useful to exclude patients
from unnecessary arthroscopy'
• Classification
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• Grade I tear
• Small disruption of homogenous signal
• Grade II tear
• Disruption is more pronounced but does not extend through either
superior or inferior surface
• Arthroscopically, a grade I or II tear cannot be visualized
• Grade III tear
• Disruption of homogenous signal with extension to either superior or
inferior surface
• A clinically significant tear
• Arthroscopy
Treatment
• Because of association of meniscectomy & late arthritis, attempt to preserve meniscus

should be the rule
• Tears not requiring Rx
• Partial thickness tears
• Tears <5 mm in length
• Tears that cannot be displaced >1-2 mm
• Options
• Conservative -> restrict activity
• Manipulative to reduce -> conservative Rx
• Operative -> arthroscopic partial meniscectomy or meniscopexy
• Meniscal transplantation - experimental
Partial meniscectomy
• For tears not amendable to repair

• In general, complex, degenerative, & central/radial tears are resected with minimal normal
meniscus being resected
Meniscal repair
• Blood supply to meniscus

• Age dependent; in adult, periphery 3 mm as well as anterior & posterior horns well
vascularised
• Within 3 mm of periphery = vascular (red-red tears)
• 3-5 mm from periphery = grey zone (red-white tears)
• >5 mm from periphery = avascular (white-white tears)
• Repair should be reserved for traumatic tears in vascular region of meniscus
• Indications: all peripheral longitudinal tears, espeacially in young patients & in conjunction with
ACL recon
• Techniques
1. Open repair
• Better preparation of tear site
• Only most peripheral of tears in red-red zone amenable to this technique
because of exposure & accessibility
• Long-term follow-up of open meniscal repairs -> success rates 84-100%
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2. Arthroscopically assisted
1. Inside-out technique
• First described by Henning
• Gold standard with vertical mattress sutures
• Utilizes zone-specific cannulas to pass sutures through joint & across
tear
• Sutures are swaged onto flexible needles
• A small posterior joint line incision is used to retrieve sutures &
tie directly on capsule
• Use of a posterior retractor is vital in order to protect posterior
neurovascular structures
2. Outside-in techniques
• Described by Warren & Morgan & Casscells
• Involve passing sutures percutaneously through spinal needles at joint
line across tear, & then retrieving sutures intra-articularly
• Mulberry knots can then be tied on intra-articular free ends of suture
• A small incision is then made at joint line, where protruding suture ends
are retrieved & tied directly on capsule
• An alternative technique
• To retrieve intra-articular portion of suture with another pass
across tear using a wire snare & tying suture back on itself on
capsule
• This technique eliminates need for Mulberry knots
• Potential disadvantage - difficulty in reducing tear & opposing edges
while passing sutures
3. All-inside technique
• Suitable for repairs of far posterior horns
• Implantable anchors, arrows, screws, & staples
• Although pullout strength of some of these devices has been shown to
approximate those of mattress sutures in cadaveric studies, there have
been no long-term clinical studies that compare them to more traditional
repair techniques
Risk of injury to peroneal nerve in lateral meniscus repair, saphenous nerve in medial repair
Healing
o Similar to other connective tissues - exudation, organisation, vascularisation, cellular
proliferation, remodelling
Following injury there is formation of a fibrin clot rich in inflammatory cells
Vessels from perimeniscal capillary plexus proliferate into this fibrin scaffold,
followed by mesenchymal cell proliferation forming a cellular fibrovascular scar
Modulation of this scar tissue into normal appearing fibrocartilage requires
several months
o ~80% of reparable menisci are found in knees with an acute or chronic tear of ACL, thus
repair of meniscus is linked to Mx of ACL tear
Aftercare
o FWB post-op
o
o Limit knee flexion to 90
o Low impact activity from 3/12
o Full activity at 6/12
Results of meniscal sutures
o 62% heal, 17% heal incompletely & 21% do not heal
o 92% clinically stable
o 80% return to active sport
o 30-40% failure rate in 5 yrs in meniscal repair in ACL-deficient knees -> need to
reconstruct ACL to protect meniscal repair
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ORTHOPAEDI UI
o Success rate in stable knees: ~90% at 9 yrs
Meniscal cysts
• Parameniscal cysts occur relatively infrequently

• Usually a/w horizontal cleavage tears but isolated cysts without meniscal pathology reported
• More common on lateral side, but some studies report an equal incidence
• Incidence 1-22%
• Typically multilocular & lined with synovial endothelial tissue
Aetiology theories
• Traumatic origin
• Purely degenerative origin
• Barrie
• Performed histopathologic studies & postulated that meniscal cyst formation originated by
influx of synovial fluid through microscopic & gross tears in substance of meniscus
• In 112 cysts, he demonstrated a meniscal tear with a horizontal component, as well as a
tract that provided an exchange of fluid between joint & cyst
• In absence of a meniscal tear
• It has been proposed that a parameniscal cyst may develop from a compression injury to
periphery of a meniscus that has central degeneration
• A meniscal cyst may then develop more peripherally, leaving body of meniscus
abnormal, but not torn
Clnical
• A meniscal cyst may present with signs & symptoms consistent with typical meniscal pathology
• Intermittent swelling at joint line is variable, while pain over area is quite common
• Pisani described that a lesion that decreases in size with knee flexion & increases with extension
is consistent with a meniscal cyst
Investigations
• MRI is valuable for confirming presence of a suspected meniscal cyst & identifying any
concurrent meniscal tear & excluding other pathologies
Management
• Diagnostic arthroscopy to determine presence of a meniscal tear

• In presence of a meniscal tear, partial meniscectomy followed by arthroscopic cyst
decompression Rx of choice
• If a tear is not confirmed at time of arthroscopy, then open-cyst decompression with peripheral
meniscal repair becomes logical Rx option, thereby leaving body of meniscus unviolated
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ORTHOPAEDI UI
• In presence of a small meniscal tear, an arthroscopic limited partial meniscectomy may be

performed, & if no tract is identified, then conversion to an open cystectomy may similarly
preserve peripheral meniscal body
OSTEOCHONDRITIS DISSECANS
Definition
• A localised condition affecting an articular surface that involves separation of a segment of

cartilage & subchondral bone
• Thought to be secondary to trauma, ischemia, or abnormal epiphyseal ossification
Incidence
• 10-15 yrs of age

• Bilateral in 20-30%
• Posterolateral aspect of medial femoral condyle in 70%
• Lateral femoral condyle in 20%
• Patella in 10%
• Another commonly affected joint: elbow (capitellum)
Guhl Arthroscopic Classification
• Lesions are classified based on (Clanton & DeLee, CORR 1982)

• Articular cartilage integrity (open or closed)
• Stability of underlying subchondral bone & its bed (stable or unstable)
• 4 types
• A - intact lesions
• B - lesions showing signs of early separation
• C - partially detached lesions
• D - craters with loose bodies (salvageable or unsalvageable)
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ORTHOPAEDI UI
Clinical
• Activity-related pain, localised tenderness, stiffness, swelling, mechanical symptoms
Investigations
• X-rays - tunnel views to evaluate condyles

• MRI - to assess fragment's articular cartilage continuity & size & viability of its subchondral bone
Natural History
• Natural history directly dependent on age at presentation

• Pappas Classification
• Juvenile type
• Completely open distal femoral physis
• Prognosis excellent if lesion is a closed, stable one
• Adolescent type
• Partial physeal closure
• Prognosis unknown because lesion may act as either juvenile or adult type
• Adult type
• Closed physis
• Poorer prognosis because of limited healing potential of lesion
Treatment (based on Pappas)
• Skeletally immature patient (<12 yrs)

• Nonoperative Rx recommended, since lesion will frequently heal if fragment has not
detached
• Articular cartilage overlying these lesions should be normal & should protect OCD defect
during healing
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ORTHOPAEDI UI
• Protected crutch walking & gentle ROM, since ROM is thought to have beneficial effects
on cartilage healing
• Skeletally mature patient (>12 yrs)
• Guhl recommends arthroscopic evaluation & Rx of all patients
• 12 yrs or older as determined by bone age roentgenograms, &
• Who have lesions >1 cm in diameter located primarily in a weight-bearing area
• Arthroscopic method
• Open arthrotomy
• Lesions that are massive (>3 cm in diameter)
• Lesions having large or multiple loose bodies that are thought to be replaceable
• Lesions that are inaccessible to arthroscopic techniques
Arthroscopic method
•
o
30 viewing arthroscope through anterolateral portal & a probe through anteromedial portal
• Removal of any loose bodies
• Carefully probe area of OCD
• Stable
• If surface basically smooth, with only an area along margin of lesion fissured & loose,
disorder is classified as an early separated lesion
• Before overlying articular cartilage has separated, antegrade or retrograde arthroscopic
drilling yields successful results
• Unstable
• Pushing on lesion with arthroscope or probe will reveal only minor movement of fragment
where articular surface defect is present
• Carefully debride this defect in articular surface with basket forceps or a small curette
through anteromedial portal
• Secure fragment in its bed using cannulated differential pitch screws (eg. Herbert), whose
low-profile head & compressive effect help prevent iatrogenic articular trauma while
promoting chondro-osseous repair
• Kirschner wires introduced under arthroscopic control have been used in the past
Other New & Experimental Rx
• For irreparable lesions in weightbearing zone

• Soft tissue grafts - periosteal/perichondral
• Chondrocyte transplantation
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ORTHOPAEDI UI
• Mosaicplasty (see Maitrise Orthopedique)
• Artificial matrix - carbon fibre, collagen, polylactic acid

• Fresh osteochondral allografts [Kish et al. Clin Sports Med 1999 Jan;18(1):45-66, vi]
Patellar OCD
• Uncommon
• Presents as mechanical knee pain during adolescence
• Occurs in distal half of patella
• 30% bilateral
• Differential diagnosis should include dorsal patellar defect, infection, or tumor
• Prognosis for patellar OCD is even less clear than it is for femoral OCD
• Subchondral bed sclerosis denotes a poor prognosis, similar to femoral lesions
• Rx principles similar to those for femoral OCD
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Spontaneous Osteonecrosis of Knee

Introduction
• 1st reported by Alback et al. in 1968: a radioluscent area in femoral condyle surrounded by a
sclerotic halo & a/w a focally active bone scan
• Believed to be an important but underestimated cause of knee OA
• Can occur in medial femoral condyle, lateral femoral condyle or medial tibial plateau
Aetiology
• Unknown
• Vascular or traumatic lesions are 2 main theories
• Trauma theory
• Elderly women, who may be relatively osteoporotic, minor trauma causes microfracture in
subchondral bone
• This allows fluids to be expressed through articular cartilage into subchondral bone &
marrow space, creating increased interosseous pressure & pain
• Increased pressure in a closed space interferes with blood supply & initiates cycle of
compromised circulation & resultant osseous ischaemia
• Secondary causes of AVN of knee
• Steroids
• Alcohol
• Renal transplantation
• Gaucher disease
• Haemoglobinopathies
• Caisson disease
• SLE
• etc
Spontaneous Osteonecrosis of Femoral Condyles

Clinical
• Typically female >60 yrs

• Sudden onset of severe pain on medial side of knee
• Pain worse at night
• Well localised tenderness over affected condyle
Radiology
• X-rays
Stage 1 Normal (In some patients a radiographically visible lesion never develops, & symptoms
resolve spontaneously)
Stage 2 Slight flattening on convexity of condyle
Stage 3 Area of radiolucency surrounded by a sclerotic area in subchondral bone
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ORTHOPAEDI UI
Stage 4 Radiolucency surrounded by a definite sclerotic halo, of variable thickness & density
Stage 5 Secondary OA changes
• Bone scans
• Increased uptake necessary to make diagnosis
• Osteonecrotic lesion appears as a focally intense area of uptake over affected femoral
condyle
• MRI
• Extremely valuable in defining osteonecrosis about knee
• T1 - discrete low-intensity signal in femoral condyle
• T2 - corresponding low signal-intensity area in central lesion, with a high-intensity signal

about margin (oedema surrounding lesion)
Prognosis
• Prognosis related to size of lesion at presentation

•
2
Large lesion (>50% of width of femoral condyle, or > 5 cm ) become disabled with increasing
pain, deformity, & eventually secondary destruction of joint
Treatment
• Making diagnosis is most NB as arthroscopy or meniscectomy are initiated before diagnosis is

established
• Only later, when condyle has collapsed, is correct diagnosis recognized
• Initially, most patients should be treated conservatively, as stage of lesion & size of osteonecrotic
segment not clearly defined
• If lesion is small, it will do well & no surgical Rx required
• Surgical options for more advanced stages
• Arthroscopic debridement
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• Proximal tibial osteotomy

• Drilling, with or without bone-grafting
• Core decompression
• Prosthetic replacement
• Allografting
Osteoarthritis of Knee
Introduction
• High prevalence: 6-12% of adult population
Aetiology
• Defects in articular cartilage

• Articular cartilage has limited ability to heal after trauma or maintain its function with
increasing age due to
• Avascular nature
• Limited ability of chondrocytes to migrate within tissue
• Defects as small as 2 mm in diameter can lead to development of OA
• Ligament rupture
• (Partial) menisectomy
• Malalignment
• Idiopathic
• Other risk factors
• Gender
• Age
• Overweight
• Nutritional factors
• Occupational factors
• Sports participation
• Quadriceps weakness
Symptomatology
• OA is characterized by progressively increasing pain, (morning) stiffness, joint deformation,

crepitations & limited ROM of involved joint
• Pain
• Usually increases after exercise & decreases at rest
• Often difficult to localise
• In more severe cases, pain can even occur after minimal usage or at rest
• Stiffness
• Mainly in morning & after prolonged rest
• Usually disappears within 10 min after minimal motion
• Joint deformity is caused by benign hypertrophic reactions at edges of joints (osteophytes), by
effusion or by synovial hypertrophy
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ORTHOPAEDI UI
• Limited ROM is caused by pain, joint destruction & inflammatory reaction of soft tissue
Radiological assessment
• X-ray
• OA is characterised by joint space narrowing, osteophytes & subchondral sclerosis
• Diagnosis
• Chaisson - sensitivity of 94-97% as long as at least 1 weightbearing AP & 1
image of patellofemoral joint obtained (either skyline or lateral)
• For patellofemoral OA, skyline views have higher sensitivity than lateral views in
predicting knee pain & osteophyte growth
• Progression
• By estimating cartilage loss as measured by narrowing of joint space
• Sensitive
• Schuss view (PA in 30 flexion) most accurate cf regular AP & weight-bearing AP
o
radiographs (with extended knee joint)

• Limitations
• X-rays have a low sensitivity in early stage OA
• Furthermore, in patients with radiological low-grade OA (grade 2+), level of
locomotor disability is not directly correlated to radiological degree of OA
• However, in radiologically more severe cases (OA grade 3+) this correlation is
much more evident
• MRI
• Valuable for analysis of less severe OA
• Higher sensitivity to monitor disease progression
• Absence of subchondral bone abnormalities & bone marrow oedema on MRI has a high
predictive value for absence of worsening of chondropathy after 1 year
• Another benefit of MRI is that other intra-articular tissues, eg. menisci & ligaments, can
be visualised
• MRI is only indicated if abnormalities other than OA are expected to be found based on
symptomatology & physical examination
Functional assessment
• Frequently used scoring systems for knee OA

• 100-point Knee Society clinical rating scale
• Originally designed for evaluation of effectiveness of TKA
• For evaluation of knee OA Rx, both in trials & in daily clinics
• Separates findings in treated knee (lag of flexion/extension, joint deformity etc.)
with findings in patient’s function (problems with ascending/descending stairs,
walking, etc.)
• Western Ontario & McMaster University Osteoarthritis index (WOMAC)
• Most commonly used outcome instrument for assessment of patient-related Rx
effects in OA
• Knee injury & Osteoarthritis Outcome score (KOOS)
• An extension of WOMAC
• Developed for younger &/or more active patients with knee injury & knee OA
Current treatment options

Physical therapy
• TENS
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ORTHOPAEDI UI
• Mechanism of analgesia is best explained by gate control theory of pain

• Immediate effect
• Reduces pain & stiffness
• Cx: skin irritation
• Contraindicated in those with demand-type pacemakers & in pregnancy
• Electromagnetic fields
• EMF causes physical stress on bone leading to generation of piezoelectric potentials
• These then act as transduction signals to promote bone formation & stimulates
chondrocytes to increase proteoglycan synthesis
• ? clinical efficacy
• Therapeutic ultrasound
• No benefit
• Low level laser therapy
• ? clinical efficacy
Oral drug therapy
• NSAIDs & COX-2 inhibitors

• NSAIDs
• Most important drawback: increased risk of UGIH
• Some NSAIDs eg. Naproxen, Ibuprofen & Indomethacin, inhibit matrix synthesis,
while others eg. aceclophenac, stimulate matrix synthesis
• COX-2 inhibitors
• Most important drawback: increased risk of MI & stroke
• Celecoxib (COX-2-I) has beneficial effect on cartilage matrix metabolism
• NSAIDs & COX-2 inhibitors equally effective in symptomatic Rx of OA, but no lasting
effect after 2 yrs
• Choice between NSAIDs & COX-2 inhibitors should be based on evaluation of risk
factors for UGIH, as COX-2 inhibitors are more expensive
• Age >65
• History of peptic ulcer disease or previous UGIH
• Concomitant use of oral corticosteroids or anticoagulants
• Possibly smoking & alcohol consumption
• Nutritional supplements
• Chondroitin sulphate - a major component of aggrecan
• Glucosamine sulphate - a normal constituent of glycosaminoglycans in cartilage matrix &
synovial fluid
• Mechanism unknown, ? stimulation of cartilage regeneration
• Results
• A Cochrane review (2005) of 8 well-controlled studies failed to show benefit of
glucosamine for pain & Western Ontario & McMaster Universities (WOMAC)
function
• Hughes & Carr -> no difference between glucosamine sulphate-treated group &
placebo group in pain assessment after 6/12
• Reginster et al. & Pavelka et al. in placebo-controlled trials -> glucosamine
sulphate had protective effect with respect to joint space narrowing & significant
improvement of symptom
• Animal study
• Protective effect by glucosamine hydrochloride, chondroitin sulphate &
manganese ascorbate on cartilage histology
• Synergistic protective effect when glucosamine hydrochloride & chondroitin
sulphate were combined, as it stimulated glycosaminoglycan synthesis
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ORTHOPAEDI UI
• Synergistic protective effect when chondroitin sulphate & manganese ascorbate

were combined, as this inhibited degenerative enzyme activity
• May affect metabolism of glucose & insulin
Intra-articular injections
• Visco-supplementation
• In OA, decrease in molecular weight & concentration of hyaluronic acid -> reduced
synovial fluid viscosity -> decreased lubricating properties
• Intra-articular injection of exogenous high-molecular-weight hyaluronic acid molecules
effective to increase synovial viscosity
• Exact mechanism of action of visco-supplementation is unclear
• ? restoration of synovial viscosity
• ? anti-inflammatory & analgesic properties
• ? stimulation of in-vivo hyaluronic acid synthesis
• Administration
• 1 injection per week for 3-5/52; higher molecular weight preparations can be
given as a single injection
• Repeat courses can be performed after 6/12
• If effusion is present, aspirate before injection to prevent dilution of injected
hyaluronic acid
• Corticosteroids
• Corticosteroids inhibit inflammatory & immune cascade at several levels
• Repeated steroid injections
• Significant reduction in clinical symptoms
• No evidence that steroids accelerated joint space narrowing
• Results
• Although some studies have described mixed results, others have demonstrated
favourable results in terms of pain relief & function for hyaluronate-based products &
corticosteroid injections
• Leopold et al. J Bone Joint Surg Am 2003;85-A:1197–203
• 100 patients in a prospective, randomized trial
• Corticosteroid vs hyaluronic acid injections
• Both Rx groups have improvement of symptoms, although not all
parameters showed a statistically significant improvement
• No differences in effectiveness between the 2 Rx groups
• Leardini et al. Clin Exp Rheumatol 1991;9:375–81
• 40 patients
• Hyaluronic acid vs 6-methyl prednisolone acetate
• Hyaluronic acid more effective than corticosteroids with respect to
duration of pain relief
• Neither Rx has been shown to be convincingly superior with respect to symptom relief &
altering course of OA
• Corticosteroids have -ve effect on cartilage matrix metabolism
• Based on high differences in cost, use of corticosteroids preferable over hyaluronic acid
Surgical treatment
• Arthroscopic debridement & lavage

• When medical Rx does not reduce symptoms, arthroscopic debridement is often
considered
131
ORTHOPAEDI UI
• Results
• Frequently reported to reduce pain
• However, no evidence that arthroscopy influences disease progression in OA
• Moseley et al. N Engl J Med 2002;347:81–8
• A controlled trial of arthroscopic surgery for OA knee
• Debridement & lavage no better than placebo Rx (sham surgery)
• Study limitations
• All patients were men & <75 yrs old, which does not represent
complete variety of OA population
• At randomization, patients were stratified for severity of disease,
but effect of Rx not reported for separate strata; possible that
debridement & lavage are more effective in less severe cases of
OA
• Power of study not high enough to conclude that results of all Rx
were identical
• Roles
• Temporising or palliative
• Especially true in patients who fail to respond to medical Mx & when arthroplasty
must be deferred because of young age
• Rx of cartilage defects
• Cartilage defects predispose to development of OA
• Mechanism not entirely clear
• Induction of inflammatory mediators & cartilage-degenerating enzymes, eg.
matrix metalloproteases
• Altered mechanical loading of cartilage surrounding defect
• Early Rx of cartilage defects can prevent development of OA if repair tissue can take over
mechanical properties of native cartilage
• Various Rx options but ? Rx of cartilage defects -> altered course of OA development
• Autologous chondrocyte transplantation (ACT)
• Autologous chondrocytes are isolated from a cartilage biopsy taken from
a non-weight-bearing area of joint, & are expanded in vitro to provide
sufficient cells for complete filling of a cartilage defect
• Cells can then be implanted, either in suspension under a flap, eg.
periosteum, or seeded on a scaffold, e.g. collagen mesh or a
biodegradable polymer scaffold
• Peterson -> clinical improvement not correlated in all cases with quality
of repair tissue
• Bentley -> ACT resulted in arthroscopically higher quality repair tissue &
functionally more improvement than mosaicplasty
• Microfracturing
• Subchondral bone plate in cartilage defect is perforated, opening up
bone marrow space
• Holes should be made as close together as possible, & microfractures
occur in bone bridging defects
• Increased amounts of repair tissue, which mostly resembles
fibrocartilage
• 80% of patients treated with microfracturing have significant reduction of
symptoms for 5 yrs
• Mosaicplasty
• Osteochondral plugs harvested from a non-weight-bearing site of joint &
implanted in defect site
• Very effective, frequently resulting in repair tissue with high resemblance
to hyaline cartilage
• Risk of donor site morbidity, especially in patients with larger defects
132
ORTHOPAEDI UI
• Osteotomy
• Frequently for unicompartmental OA
• Can decrease symptom & increase radiological joint space width
• ? mechanism
• Altered mechanical loading of joint
• Formation of newly synthesized fibrocartilaginous tissue
• Viable approach to postpone need for arthroplasty
• Valgus producing osteotomies should be overcorrected beyond mechanical axis of joint,
thereby improving long-term results
• Sprenger & Doerzbacher -> alignment between 8-16 of valgus after osteotomy
o
for varus gonarthrosis -> significant improvement in survivorship of Rx (end

points defined as TKR, Hospital for Special Surgery knee score of <70 points, or
patient dissatisfaction)
• Yasuda et al -> overcorrection of 5-8 -> optimal functional results
o
• Varus producing osteotomies have equally beneficial results but there is a disagreement
as to optimal correction angle
• Overcorrected -> increased deterioration rate of medial compartment
• Others suggest overcorrection between 6-7 for mechanical axis
o
• Joint line obliquity should be <10 , otherwise, increased shear forces & increased risk of
o
subluxation -> higher cartilage degeneration rate

• Joint replacement surgery
• Proven to be highly successful in elderly patients, relieving pain & resulting in restoration
of function
• However, higher failure rates in young & early-middle aged patients, due to
• Higher physical activity -> wear & loosening of prosthesis
• Higher expectations with respect to post-op improvements
• Complications, eg (septic) prosthesis loosening -> high morbidity & revision arthroplasty
does not have similar survival rates
• Arthrodesis
• Highly effective in Rx of pain
• However, very disabling due to immobility of joint, especially in younger & more active
patients
Future directions
• Further Ix, both in clinical trials & in fundamental research, is necessary to elucidate which Rx
strategy is optimal with respect to reduction of symptoms & possible protective effect against OA
progression
• Inflammatory cytokines
• Several studies have shown that joint homeostasis, environment of articular cartilage, is
disturbed in a damaged joint, & as a result it stimulates progression of OA & inhibits
healing
• Inflammatory cytokines appear to play an important role in this process & IL-1b is
frequently proposed to be a key factor
• IL-1
• Induces collagenase & prostaglandin production -> catabolism of cartilage
• Decreases synthesis of cartilage-specific collagens & proteoglycans
• However, other inflammatory cytokines may also play an important role in this process, or
even might be more important than IL-1b
• In some studies IL-1b concentration on synovial fluid from OA joints was below
detection level, while increased concentrations of cartilage metabolism modifying
inflammatory cytokines, eg TNF-a & IL-6, were found
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ORTHOPAEDI UI
• Application of IL-1 receptor antagonist could not restore cartilage metabolism in

vitro in cartilage explants cultured co-incubation with synovial tissue from OA
joints
• Inflammatory cytokines, eg. IL-6, IL-17 & IL-18, have a negative effect, while
antiinflammatory cytokines, eg. IL-4, IL-10 & IL-13, are capable of restoring cartilage
metabolism
• Growth factors
• Gene therapy
• Biphosphonates
• Hormone replacement therapy
• Matrix metalloproteinase inhibitors
Prevention
• Gender & age - post-menopausal women on oestrogen therapy have a lower prevalence &
incidence of radiographic OA
• Overweight
• Kohatsu -> subjects with OA were 3.5x more likely than controls to have been obese at
age of 20
• Felson -> women who lost 11 lbs decreased risk for knee OA by 50%
• Williams & Foulsham -> weight loss resulted in significant reduction of symptoms of OA
• Reactive oxygen radicals, eg. nitric oxide, play an important role in pathogenesis of OA
• Framingham study -> subjects in middle & highest tertile of vitamin C intake had a 3x
reduced risk for radiographic progressive OA
• Vitamin D & E, however, have not been shown to have a protective effect
• Risk factors, eg occupational factors, sports participation & quadriceps weakness all have to do
either with risk of trauma or repetitive high (torsional) strain on knee joint & provide a feasible
point of impact for prevention or altering course of OA
TOTAL KNEE REPLACEMENT

TKR - Indications & Pre-operative Management
Indications
• Primary objectives
1. To relieve pain
2. To provide motion with stability
3. To correct deformity
• Conservative Rx should always be prescribed 1st
o Medical Rx
o Physiotherapy
o Weight reduction
o Controversy exists on usefulness of
• Steroid & hyaluronic acid injections
• Arthroscopic lavage & debridement
• Shoe insoles
• Bracing
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ORTHOPAEDI UI
In presence of appropriate symptomatology, TKR indicated in

0. RA - regardless of age, including JCA
1. OA
• Consider age, weight, occupation, sex, activity level
• Avoid in <60 yo, manual labourers, high demand patients, obese
2. Post traumatic OA - rare indication in younger patient
3. Failure of HTO
4. Patellofemoral OA
• Rare in isolation
• If so, best Rx in older patient is TKR
5. Neuropathic joint
• Controversial
• Insall believes it is feasible as long as correct alignment & stability achieved
Contraindications
• Recent or current sepsis

• Age (relative)
• Stable arthrodesis
• Prospects of a successful arthroplasty not good
• A constrained prosthesis usually required
• In the event of failure rearthrodesis may not succeed
• Neuropathic joint
• Quadriceps weakness
• Arthrodesis better choice
• Genu recurvatum
• Associated with muscular weakness or paralysis is likely to recur following TKR & places
stresses on prosthesis which increase likelihood of loosening
Pre-operative Management
Preop assessment
• Indication & contraindications

• Infection
• Dental evaluation
• Nasal & perineal swabs for MRSA
• FBC, U+Es, MSU
• Medical/dental/GI/urological evaluation
• Medications
• Aspirin & other antiinflammatory drugs should be discontinued 7-10 days before surgery
• Anticoagulant should be discontinued in sufficient time for bleeding & clotting times to
return to normal
• Transfusion
• Preop Hb main indicator for need of postop transfusion
• Hb <11 g/dl strong indicator for need for transfusion
135
ORTHOPAEDI UI
• Consider preop donation of blood, or GXM

• Autologous blood
• 2 units for primary hips or cell saver
• Disadvantages: time consuming, expensive, significant decrease in preop Hb
level (which actually increases likelihood of transfusion), possibility of clerical
error, possibility of transfusion reaction
• Erythropoitin
• Physical exam
• Previous incisions
• Extensor mechanism
• Deficient extensor mechanism, consider medial gastrocnemius transposition flap
(Jaureguito et al 1997)
• Quadriceps contracture (knee flexion limited) - temporary lengthening of extensor
mechanism required
• Limb length
• Hip deformity
• Inability to flex hip relative contraindication to TKR
• Generally hip arthroplasty should be performed prior to knee arthroplasty
• Hip flexion needed to perform TKR
• Hip is more tolerant of delayed rehab than is knee
• Knee deformity
• Lateral subluxation (varus thrust): release popliteus tendon
• Varus deformity
• Note whether varus/valgus deformities are fixed vs flexible
• Important to distinguish between fixed varus & a knee with pseudolaxity
due to loss of medial joint space
• In later case, MCL may be attenuated & can easily be "overstripped"
during initial exposure
• With a fixed varus knee, further capsular elevation may be required
• Valgus deformity
• If significant valgus deformity has been corrected, consider lateral
retinacular release to allow proper patellar tracking & prevent patellar
subluxation
• Consider subvastus approach to preserve blood supply to patella
• Release of IT band, LCL, posterior capsule may all be necessary
• Flexion contracture of knee
• 10 mm resection of distal femoral cortex may be preferable
• Recurvatum
• Usually a/w limitation of full flexion
• Correction involves not only filling extension space with thick tibial
implant, but also lengthening of quadriceps
• Foot deformity
• Valgus foot puts valgus strain upon knee
• Correction of ankle deformity advised before TKR
• Vascular status
• Pulses dopplerable but not palpable, avoid use of tourniquet
• Pulses dopplerable but not palpable in diabetic patient, consider vascular surgery
consult
• Pulses not dopplerable, case should be delayed until vascular consult obtained
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ORTHOPAEDI UI
Preop planning
• X-rays
• Standing AP view: full-length from hip to ankle
• Lateral view: standing extension & flexion views
• Skyline view of patella
• Planning & templating
• Surgical approach
Consent
Antibiotic prophylaxis
UKR
•
o o o
Clinical - FFD <15 , flexion >90 , varus <15
• Need to accurately assess anatomic/mechanical axes of joint preop
• Lateral X-rays - tibia erosion not extending to back (95% predictive of intact ACL)
• Bone scan preop - if increased activity on other side -> do not do hemiarthroplasty
TKR - Design & Mechanics
Biomechanics & Design Considerations

Alignment Axes
• Mechanical axis of lower limb

• Extends from center of femoral head to center of ankle joint & passes almost through
center of knee (medial side)
• 3 varus from vertical axis
o
• Anatomic axis of femur

• 6 varus from mechanical axis
o

o
• Anatomic axis of tibia

o
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ORTHOPAEDI UI
• Femoral component should be inserted in 9 ± 2o of valgus from anatomical axis

• Inability to achieve precise alignment will ultimately lead to component loosening -> leading
cause of TKR failure
Design Considerations
• Requirements for TKR

• Axis of rotation: 15-20
o
• Medial-lateral motion: 5-10

o
• Flexion requirements
• 65 to walk at a normal pace
o
• 95 to walk up & down stairs

o
• 110 to arise from chair

o
• Femoral roll back

• As knee flexes, femur rolls back on tibia
• Increases potential for further flexion by preventing posterior structures
from impinging
• Increases length of quadriceps moment arm
• Without roll back, effective strength of quadriceps is reduced by
~30%
• With PCL sacrificing TKR, posterior projection of femoral condyle should, ideally,
be as large as possible
• Summary of types of design
Compartment Bicompartmental
Tricompartmental
Unicompartmental
Patellofemoral replacement
Constraint Unconstrained - non-conforming
138
ORTHOPAEDI UI
Semiconstrained - conforming
Fully constrained - hinge/link
Conformity Conforming
Non-conforming
PCL PCL retention - non-conforming

PCL sacrificing – conforming
Bearing Fixed
Mobile
Factors Affecting Choices
• Mechanical
• Stability
• ROM
• Roll back
• Sliding
• Stress
• Biological
• Technical
• Financial
Types of Design
• Bicompartmental - historical
• Tricompartmental
• Unconstrained
• Depend on soft tissues for stability; mobile meniscal-bearing surfaces of tibial
component (= LCS prosthesis)
• Non-conforming
• Flattened tibial surfaces
• Allows rotational & AP movement, & roll-back
• But line & point loading in extension
139
ORTHOPAEDI UI
• Semiconstrained
• Conforming
• Concave tibial component surface
• Prevents excessive slide & contact stresses; maximum stability
• But less flexion by limiting roll-back
• Fully Constrained
• Hinge/link mechanisms
• For knees with instabilities & deformities too severe for adequate correction with
semiconstrained types
• Because movement in 1 or more planes restricted -> high stresses in implant &
interfaces -> wear & loosening
• Unicompartmental/condylar - for patients <60 yrs, with medial compartmental OA where varus
deformity is mild
• Patellofemoral replacement
PCL Retention vs PCL Sacrificing

PCL Retaining (non-conforming)
• Advantages
• Preserves proprioception
• Encourages femoral roll-back -> increasing ROM & quadriceps moment-arm
• Protects against posterior subluxation
• Better kinematics - more normal stair climbing gait, no difference in level gait
140
ORTHOPAEDI UI
• Disadvantages
• Exposure may be more difficult
• More difficult collateral balancing
• Need to reproduce preop joint line or JRF -> wear
• Posterior laxity if too loose
• 'Nutcracker' effect if too tight
• Less conforming surface required to allow roll-back & slide -> increased contact stresses
• Sliding causes high subsurface stresses (delamination)
PCL Substituting (conforming)
• By adding central cam mechanism to articular surface geometry of Total Condylar prosthesis
• Udomkiat P et al Clin Orthop 2000 Sep;(378):192-201

• Functional comparison of posterior cruciate retention & substitution knee replacement
• 38 matched pairs of DJD knees from patients who underwent TKR with minimum 2 yrs of
follow up
• No statistically significant difference in clinical evaluations
• Fluoroscopic kinematics -> PS knee experienced AP femorotibial translation more similar
to normal knee during normal gait & deep knee bend
PCL Sacrificing (conforming)
• Advantages
• Technically easier & reproducible
• Greater articular interface conformity to provide AP stability a/w reduced surface stresses
• No sliding
• Disadvantages
141
ORTHOPAEDI UI
• No roll-back -> limited in flexion by posterior impingement of femur on tibial polyethylene

component
• Increased constraint a/w conformity increasing stresses at fixation interface
• Proprioception & kinematics may be affected
• Long-term follow-up reveals no difference in performance & survival
Metal Backing of Tibial Component
• Metal tibial tray should be at least 3 mm thick for strength

• Advantages
• Less stress in underlying bone
• Stresses more evenly distributed
• Contained polyethylene -> less cold-flow & bending of polyethylene
• Prevents 'wing-up' phenomenon
• Permits modularity
• Disadvantages
• Thinner plastic -> increased stress in UHMWPE (need min 6 mm thick)
• Eccentric loading may -> tilting
• Stress shielding of underlying bone
• More expensive
• There may be a place for all-plastic tibial components in elderly
Fixation
• Cement
• Remains gold standard
• Scuderi et al "Survivorship of cemented knee replacements" JBJS 71B: 798-803, 1989
• Posterior stabilised prosthesis - 15 yr success rate of 90%
142
ORTHOPAEDI UI
• All polyethylene tibia - 10 yr success rate of 97%

• Metal backed tibia - 7 yr success rate of 98.75%
• Cementless tibial components
• More prone to failure than cemented
• Probably due to failure to obtain sufficient initial stability for adequate bone ingrowth
• Thus hybrid TKR is now being performed
• Early results are equal to all cemented
• Wright et al CORR 260: 80-86, 1990
• Hybrid - good or excellent in 93%
• No sign of component loosening
Unicompartmental/Unicondylar knee replacement
• Serves a specific niche for knees too severe for arthroscopic Mx of medial DJD (mosaicplasty)
but not severe enough for TKR
Criteria for UKR
• OA in anteromedial compartment only

• Intact ACL (not anymore: ACL recon + UKR)
Absolute contraindications
•
o
Flexion <90
•
o
Valgus >15
•
o
Varus >15
• Lateral compartment OA
Advantages
• Avoid PFJ overload

• Retains knee kinematics
• Restores limb length
• Better flexion
• Less blood loss
• Rapid rehab
• Cheaper
Disadvantages
• Can have point loading -> higher revision rate
143
ORTHOPAEDI UI
Preop assesment
•
o o o
Clinical - FFD <15 , flexion >90 , varus <15
• Need to accurately assess anatomic/mechanical axes of joint preop
• Lateral X-rays - tibia erosion not extending to back (95% predictive of intact ACL)
• Bone scan preop - if increased activity on other side -> do not do hemiarthroplasty
Results
• 10 year survival = 98%

• UKR vs osteotomy
• Function & gait better at 1 yr
• 10-17 yr survival better
• UKR revision easier than osteotomy
TKR - TECHNICAL CONSIDERATIONS
BACKGROUND
• Primary stabilisers about knee are ligaments & muscles as bony contours offer little resistance to
displacement
• Walking on level ground joint is subject to 3x body weight & going up stairs 4x body weight due to
effect of muscle action
• Load to tibia not distributed evenly with medial tibial plateau taking greater load than lateral
• Bone grafting of tibial plateau indicated
• If >50% of plateau -> defect
• If cement column under prosthesis would measure >5 mm in height
• Normal gait requires
• 67 of flexion in swing phase
o
• 83 of flexion for stair climbing

o
• 90 of flexion for descending stairs

o
• 93o of flexion in rising from a chair
AIMS
• Restoration of
1. Normal mechanical axis of leg
• Allows optimal load share through medial & lateral sides of components
2. Soft tissue balance of knee to optimise biomechanics of knee
• Provides optimal function & wear of prosthesis
3. Knee joint line level
• Knee ligaments play a vital role in prosthetic knee kinematics
144
ORTHOPAEDI UI
4. Normal patellar tracking (Q angle)
EXPOSURE
Skin Incision
• Longitudinal midline or medial parapatellar skin incision

• In revision surgery, use most lateral incision usable, as superficial blood supply comes mainly
from medial side of knee
Deep dissection
1. Medial parapatellar capsular
• Most common
2. Subvastus
• Vastus medialis reflected laterally

• Advocates -> less interference with extensor mechanism, but difficult to obtain good view in
obese
145
ORTHOPAEDI UI
3. Lateral parapatellar approach
• Sometimes used in very valgus knee

• For difficult primary or revision TKR, to protect tibial tubercle from avulsing on lateral rotation of
patella
4. Quadriceps turndown
• For exposing a stiff or ankylosed knee when standard exposure will risk damage to tibial tubercle
• Standard medial parapatellar approach with additional limb extending laterally
• Beware of lateral superior genicular artery
• Can be converted into a Y on closure if there has been quads contraction secondary to knee
stiffness
•
o
Stitch in position where gravity alone will allow flexion to 90
• Postop active extension should be delayed & splint used for walking for 2-3/12
5. Rectus snip (Insall)
146
ORTHOPAEDI UI
6. Tibial tubercle osteotomy (Whiteside)
• 3-6 cm length
• Tibial tuberosity still attached to lateral musculature
• Fix back with screws
Bone preparation & ligamentous balancing
• Successful surgical replacement of articulating surfaces by prosthetic components can only be

achieved when proper knee & limb alignment as well as soft tissue equilibrium are restored
• 2 types of surgical techniques
• Bone referencing technique
• Bony landmarks used for restoration of osseous alignment, with subsequent soft
tissue balancing after bone cuts
• Ligament referencing technique (‘‘tibia cut first technique’’ or ‘‘LCS technique’’)
• Tibial cut made 1st, with subsequent ligament balancing, which is only followed
by other bone cuts when adequate soft tissue equilibrium has been obtained
• No outcome data exist today to support one over the other
• Because current instruments are a/w some degree of imprecision, computer-assisted surgery
was recently introduced
147
ORTHOPAEDI UI
Mechanical alignment
• Aim for mechanical axis passing through middle of proximal tibia -> optimal load share through
medial & lateral sides of components
• Varus or valgus malalignment -> excessive stress on 1 side -> excessive wear & increased
component loosening
•
o o
Cut tibia 90 to mechanical axis of limb with a posterior slope of 0-5 depending on design of
prosthesis
• Both extra- & intramedullary guides available
• Use extramedullary when deformity is present eg. tibial bowing, malunion of #
•
o o
Cut distal femur at 5-7 valgus from anatomical axis of femur, ie. 90 to mechanical axis
• Use intramedullary alignment jig if possible
• Otherwise, valgus cut angle should be measured with full-length X-rays in
• Very tall or short
• Post-traumatic deformities of femur
• Congenital femoral bow deformities
• Amount of bone taken off should be equivalent to thickness of femoral component
Femoral sizing
• Size femoral component to avoid notching of femur
Rectangular flexion gap
• To make flexion gap rectangular & to enable normal patellofemoral tracking, place femoral cutting
o
block on femur so there is external rotation of block of ~3 in relation to posterior condyles
because tibial cut has been made perpendicular to mechanical axis of leg
• Identify neutral femoral rotational axis based on bony landmarks

1. Epicondylar axis - slightly externally rotated to neutral axis
2. Whiteside line (AP axis of femur) - from centre of trochlear groove to top of intercondylar
notch
3. Posterior condylar axis
4.
148
ORTHOPAEDI UI
• M
a FLEXION GAP FLEXION GAP OK FLEXION GAP TIGHT
k LOOSE
e
EXTENSION GAP Potential problem: Potential problem: Potential problem:
LOOSE unstable knee unstable in extension unstable in extension, restricted
p flexion
o
s
t
e
r Solution:
i Solution:
o
r
1. augment femur distally, downsize femur to increase flexion
& Solution: or gap, then use thicker plastic insert
thicker plastic insert
c 2. downsize femur (cut off
h more posteriorly) to
a
increase flexion gap, then
m
f use a thicker plastic insert
EXTENSION
e GAP Potential problem: You are a wonderful Potential problem:
OK
r unstable in flexion surgeon restricted flexion
c
u
t
s Solution: Solution:
resect more from 1. downsize femur to increase flexion
o distal femur to gap
n increase extension
gap, then use 2. Slope tibia more posteriorly to
f
thicker plastic insert increase flexion gap
e
EXTENSION
m GAP Potential problem: Potential problem: Potential problem:
TIGHT
u limited extension, limited extension restriction of flexion & extension
r unstable in flexion
u
s
i Solution:
n Solution:
g Solution: 1. thinner plastic insert but not <10
1. resect distal mm
c femur to increase 1. resect distal femur to
u extension gap, increase extension gap 2. resect tibia which increases flexion
t
thicker plastic insert & extension gap equally
t
i 2. release capsule
n 2. release capsule posteriorly
g posteriorly, thicker
plastic
j
ig (jigs)
149
ORTHOPAEDI UI
Flexion & extension gap
•
o
Flexion gap assessed with knee in 90 of flexion
• Extension gap assessed with knee in full extension
• Flexion gap & extension gap should be rectangular & roughly equal to each other
• Assess using laminar spreaders or spacers or trial prostheses
• Always check flexion gap first & adjust extension gap accordingly
• Slight residual varus laxity in extension better tolerated than valgus laxity in extension because of
stabilising effect of iliotibial band (see table)
Lateral side narrow Lateral release

Thicker plastic insert
Medial side narrow Medial release
Thicker plastic insert
To make flexion & extension gaps equal
Correction of preoperative deformities

Varus deformity
• Most common deformity of osteoarthritic knee

• During initial exposure OCD SSP CP
• Removal of medial femoral & tibial osteophytes
• Release of capsule & deep medial collateral ligament off tibia
• Release of posteromedial corner along with attachment of semimembranosus
aponeurosis
• Release of proximal tibia subperiosteally lifting superficial MCL & pes anserinus
insertions in continuity with periosteum
• If greater degree of deformity, may release posteromedial capsule & PCL
• Consider more distal stripping of periosteum on tibia if necessary
• If over-release occurs, a constrained knee device is required
Valgus deformity
• Occurs in rheumatoid arthritis due to stretching of medial capsule & ligaments

• Occurs in OA with hypoplasia of lateral femoral condyle with associated flexion or external
rotation contracture
• Most bone loss is femoral rather than tibial
• Consider lateral parapatellar approach
• Use no greater than 5o femoral cut
• Be careful not to internally rotate femoral component (can build up worn lateral condyle with
Bristow before fixing jig for ant. & post. cutting)
• Don't use 3o external rotation
• Order of lateral releases OCLIPLIPS
• Osteophytes removal
• Capsule (lateral) released from tibia
• Lateral patellofemoral ligament
• Iliotibial band at level of joint/Gerdy's tubercle (if tight in extension)
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ORTHOPAEDI UI
• Popliteus (if tight in flexion)

• Lateral collateral ligament from femur
• Intermuscular septum
• PCL as it can act as a central tether
• BicepS tendon off fibula head
• If a/w flexion contracture, posterolateral capsule & lateral head of gastrocnemius should
be released from femur
• Occasionally medial collateral ligament is so attenuated that balance cannot be achieved; options
available then
• MCL advancement
• Constrained knee replacement in elderly
• Varus/valgus constrained (VVC) prosthesis
• Do femoral & tibial cuts before posterolateral corner releases
• Some authors routinely expose common peroneal nerve if flexion & valgus deformity, & splint
knee in some flexion postop to protect it & then slowly stretch it by gradually extending knee
Flexion contracture
• Strip adherent posterior capsule from femur after femoral cuts made
• Removal of posterior osteophytes with a curved osteotome
• Elevation of posterior capsule & division of PCL
• May release tendinous origins of gastrocnemius
• Another alternative is to remove more distal femur but this raises joint line & function of collaterals
if excessive
• Need to fully correct fixed flexion completely at op questionable
Management of bony deficiency
• Causes of bony defects

• Arthritic angular deformity
• Hypoplasia
• Avascular necrosis
• Previous surgery
• Types of bone defects
• Contained - an intact rim of cortical bone surrounding deficient area
• Uncontained - more peripheral with lack of a bony rim
Small contained defects Cement

Small uncontained defects <5 mm Cement
Large contained defects Impacted cancellous bone graft
Large uncontained defects Structural bone graft
Metal wedges
Blocks
Screw augmented cement
Surgical problems with a previous high tibial osteotomy
• Outcome of TKR in previous tibial osteotomy less successful than primary TKR
• Thought to be due to patella infera (baja)
151
ORTHOPAEDI UI
• Respect a lateral longitudinal scar, at least 8 cm should be allowed between a new midline & old
lateral incision
• If patella infera noted, consider tibial osteotomy with proximal sliding
• Subperiosteal exposure more difficult after osteotomy
• Since ligamentous balancing may be difficult some surgeons recommend PCL sacrifice &
substitution
• If a large lateral closing wedge osteotomy has been performed, there may be a lateral
uncontained bone defect on tibia, requiring augmentation
• Medullary canal of tibia may be offset in relation to centre of tibial tray
• Extramedullary alignment will be necessary
• Tibial tray may require an offset peg to accommodate deformity
Previous patellectomy
• Theoretically 4 bar linkage of quads tendon, patella tendon & cruciate ligaments is disrupted by
patellectomy, so PCL incapable of maintaining long term sagittal plane stability
• Some therefore feel that PCL substituting replacements better than PCL retaining replacements
(evidence conflicting in literature)
• Quadriceps weakness can be a problem
Joint Line
• Level of joint line should be maintained as close to normal as possible, esp if using PCL retaining
design where tension of retained PCL must be as normal as possible to ensure FROM & even
pressure transfer throughout ROM to tibial component
• Joint line elevation
• Increase in vertical distance from original articular surface to newly reconstructed
surface, from a fixed point on tibia
• Can affect
• PCL function
• Collateral ligament function
• Patellofemoral joint mechanics
• Can occur due to
• Excessive medial or lateral releases & insertion of thicker plastic inserts
• Undersizing of femoral component can lead to a larger flexion gap than extension
gap -> to balance them, more bone may need to be removed from distal femur ->
this elevates joint line
Patellofemoral Tracking
• Any factor that causes increase in Q angle can cause lateral maltracking of patella
• Internal rotation of tibial component lateralises tibial tubercle so increases Q angle ->
patellar maltracking
• Align tibial component to point to medial 1/3 of tibial tubercle
• Internal rotation or medial translation of femoral component causes trochlear to be more
medial increasing Q angle
• Aim for 3-4° ER of femoral component to improve patellar tracking
152
ORTHOPAEDI UI
• This amount of rotation also helps equalise collateral structure balancing as

lateral collateral structures are slightly more lax in flexion
• Femoral component position should be either centred or lateralised
• If patella resurfaced, prosthetic patella should be medialised, not just placed in middle of available
bone
• Increased anterior displacement of patella during knee motion can lead to patellar instability or
limited flexion
• Due to an oversized femoral component
• Underresection of patella before resurfacing
• Use no thumb test throughout ROM of knee
• If it stays in groove then tracking adequate
• If it laterally subluxes, inspect knee for above problems
• If none of above problems present, perform lateral retinacular release from inside out
Wound Closure
• No benefit in taking tourniquet down prior to closure in terms of blood loss (Burkart et al)
• Routine use of suction drainage questionable (Beer et al)
• Use of femoral intramedullary bone plug has been shown to reduce blood loss by 20-25%
OTHER ISSUES
Haemophilia arthropathy
• Less good results in terms of ROM & postop Cx

• Perioperative Factor VIII should be maintained at 100% for 3/7 postop
Diabetics
• Increased wound infection
TKR - Postoperative Care

Physical therapy
• ROM post TKR

• Single most important factor predicting ultimate ROM -> ROM before surgery
• Generally, post-op flexion range = pre-op flexion range +/- 10
o
• Patients with significant stiffness before surgery will have most difficulty gaining ROM
• Post-op flexion contractures, usually due to hamstring tightness & spasm, will stretch out
in 6-12/12
153
ORTHOPAEDI UI
• Lateral retinacular release & sacrifice or retention of PCL, do not significantly affect knee
ROM after surgery
• Final ROM after knee arthroplasty is fairly similar among various prosthetic designs, &
o
usually ~100-115
• CPM
• May result in faster recovery of motion immediately post-op, but appears not to ultimately
increase ROM at 1 yr post-op
• Downside is possible wound healing problems, due in part to decreased transcutaneous
pO2
• Some recommend maximum flexion be limited to 40 for 1st 3/7
o
• Knee wounds closed in flexion tend to recover quicker & do not require use of CPM
• Manipulation
• Manipulation may be indicated in some cases of limited postop knee flexion
• Manipulation at 2-3/52 postop can significantly increase knee flexion, but ultimate ROM
may not show any improvement over knees which did not receive CPM
• CNA Esler et al
• MUA on 47 knees
• Inclusion: flexion <80 at mean of 11/52 postop
o
• Goal: to overcome intra-articular adhesions

• Delaying manipulation well beyond timing of earlier studies important in
maintaining gains in flexion
• Mean gain in flexion at 1 yr was 33
o
• Cx
• Hemarthrosis
• Supracondylar femur #
• Wound dehiscence
• Patellar tendon rupture
Osteoporosis
• Alendronate
TKR - Complications
Local
Intraoperative
Neurovascular damage
Ligamentous injuries
Perioperative
Sepsis
Wound healing
Postoperative
Loss of quadriceps power

Limited ROM
154
ORTHOPAEDI UI
Periprosthetic fractures
Loosening
Polyethylene wear
Problems of patella
Patellar tendon avulsion

Patellar resurfacing
Patellofemoral instability
Systemic
Fat embolism
DVT/PE
Others
Prognosis
• 94% 11 yr survival for total condylar prosthesis

• Specific groups
• TKR after patellectomy
• Joshi et al JBJS 76B: 926-929, 1994
• 19 patients, avg follow-up 63/12
• High Cx rate - 36% overall
• 3 supracondylar #, 3 coronal instabilities (no AP instabilities)
• TKR in severe deformity
• Karachalios et al JBJS 76B: 938-942, 1994
• 51 knees with varus or valgus >20
o
• 14 knees had persisting deformity esp. in case of valgus, 4 knees with valgus
o
>30 had lateral dislocation/subluxation of patella post TKR
Complications
Intra-operative
• Neurovascular damage
• Arterial damage rare <0.05%
• Peroneal nerve damage
• Usually in correction of flexion & valgus deformity
• Prognosis - all have partial recovery, 1/2 full
• Ligamentous injuries
• Blood loss ~1500 ml
• Fat embolism a/w stemmed intramedullary components & guides
Perioperative
155
ORTHOPAEDI UI
• Sepsis
• Wound healing - problems in RA, diabetes, haematoma, low albumin, leucopenia
Postoperative
• DVT/PE
• DVT evident on venography in 50-70% of patients & asymptomatic PE in 17% of patients
• Prevalence of DVT after primary TKR higher than after primary THR due to calf-vein
thrombosis
• Prophylaxis with
• Warfarin -> Cx in 17% of patients
• Low molecular weight heparins -> relative risk reduction of DVT ~50%
• H M Wakankar et al (JBJS Vol 81 Jan 1999 p 30)
• No increased risk of DVT in patients that received a tourniquet
• But study criticized for having too few patients to make reasonable conclusion
• Loss of quadriceps power
•
o
Limited ROM (<90 flexion)
• Fractures
• Loosening
• Most common Cx & increases with time & in association with more constrained
prostheses
• Major cause: malalignment, poor cement techniques
• Wear debris uncommon in TKR but may be a problem with patella prostheses
• Polyethylene wear
• Predominantly adhesive/abrasive wear
• Catastrophic wear - premature failure of prosthetic implants due to excessive loading,
macroscopic failure of PE, & subsequent mechanical loosening
• Influenced by
• Polyethylene thickness
• Presence of metal backing -> thinner PE -> yield strength exceeded
• Articular geometry
• Less conforming surfaces have more point loading -> wear
• Sagittal plane knee kinematics
• In PCL-retained TKRs, rollback is a combination of forward sliding,
backward sliding & posterior rolling
• Flat PE insert required also
• Sliding movements -> surface & subsurface cracking & significant wear
• PE sterilisation
• PE machining
• Limb alignment
• Modularity
• May get wear between polyethylene & metal backing
• Problems of patella
• Patellar tendon avulsion
• Increased risk in revision TKR, prior HTO
• Treat with primary repair
• Patellar resurfacing
• Rules of 10%
• 10% anterior knee pain if not resurfaced
• 10% Cx if resurfaced & account for almost 50% of all long term Cx of
TKR
• Patellar clunk syndrome
156
ORTHOPAEDI UI
• Patellar instability
• Lateral facet irritation
• # & AVN
• Loosening
• Wear
• Therefore, selective resurfacing
• Anterior knee pain
• PFJ X-ray changes
• Osteoporosis
• Obesity
• Old age
• Maltracking
• <20 mm of patella thickness relative contraindication for patellar resurfacing
• Original patella height should be restored
• Patellofemoral instability
• Causes
• IR of tibial component
• IR & medial translation of femoral component
• Residual valgus deformity
• Inadequate resection of bone in resurfacing -> too thick
• Failure to check tracking
• Treat by release or distal realignment
Knee Osteotomies
INTRODUCTION
• 60% of load of body weight passes through medial compartment of knee

• Loads up to 4x body weight are produced on climbing stairs
• Osteotomy redistributes loads to uninvolved compartment
• Narrowed medial cartilaginous space may regenerate (& associated degenerative features may
reverse)
• ROM is not likely to improve with osteotomy
• Of note several months need to elapse before patient is fully mobile, & it is often a year or more
before patient is free of pain
INDICATIONS
• Unicompartmental disease
• Radiologically intact lateral (or medial) & patellofemoral compartments
• Angular deformity
• <15 of fixed varus deformity (often patients will have varus laxity)
o
• <15 of flexion contracture

o
• >90 of knee flexion

o
• Physiologic age <60 yrs in an athlete, laborer, or anyone who needs to kneel down eg. for
gardening
157
ORTHOPAEDI UI
• Weight >80 kg at increased risk for component failure
CONTRAINDICATIONS
• ACL tear
• RA & inflammatory arthritis
• Tibial subluxation >1 cm
• Osteochondral injuries with involvement of >1/3 of condylar surface or OCD lesion of >5 mm
deep
CLINICAL
• Observe patient walk (look for varus thrust)

• Stability
• Q angle
• Compensatory arc of motion of hip
• To correct a valgus knee deformity
• For a 20 varus osteotomy, 20 of abduction at hip is required so patient does not end up
o o
with an adduction deformity

• Examine foot & ankle to rule out fixed varus deformities which may worsen medial compartment
loading
• Leg length discrepancy
• Coventry closing wedge osteotomy might be indicated, where as, if arthritic side is
shorter, then consider opening wedge osteotomy
INVESTIGATIONS
• Radiology
• Standing long-leg film with patellae facing forward (rather than patient's feet)
• Mechanical axis = centre of femoral head - medial tibial spine - centre of ankle
joint
• Weight-bearing axis = centre of femoral head - centre of ankle joint
• Anatomical axis = line along axis of femur to intercondylar notch & line formed by
interspinous region to centre of ankle
• Supine films
• Arthroscopy
METHODS
• Medial compartment disease

• High tibial osteotomy (HTO) above tibial tubercle
• Lateral closing wedge & fibular shortening
• Overcorrection of mechanical axis by 3 is ideal
o
• Cx
• Undercorrection - most common
• Overcorrection
• Penetration of articular surface
• AVN of tibial plateau
• Patella baja
158
ORTHOPAEDI UI
• Peroneal nerve injury

• Anterior compartment syndrome
• TKR may be more difficult
• Lateral compartment disease
• <12 valgus = varus tibial osteotomy
o
• >12 valgus = medial closing wedge osteotomy of distal femur (supracondylar)

o
RESULTS
• Satisfactory results obtained in as many as 70% at 10 yrs have been reported (study of 51 knees
JBJS, 1988)
•
o o
Best results obtained if slight over-correction achieved that is 2-3 beyond normal 7 of valgus
• Results relate to preoperative knee scores & degree of correction/over-correction of mechanical
axis
• Odenbring et al 1990
• 75% of patients under age of 50 with early medial DJD had good result at 11 yrs post
surgery
• Billings et al (JBJS 1999)
• 64 valgus producing high tibial osteotomies were performed using a calibrated cutting
guide with plate fixation
• 43 out of 64 knees had a good to excellent clinical result with an average knee score of
94 points at an average of 8.5 yrs follow up
• Using total knee arthroplasty as an end point, there was 85% survival at 5 yrs & 53% at
10 yrs
• No patient had patella baja postoperatively (authors felt that early ROM with CPM
prevented baja)
• Average initial postop correction for all knees was to 9.2 ± 3.69o of valgus
• 5 knees were corrected to <5 of valgus
o
• 3 of them were treated with a subsequent arthroplasty (at 24, 65, & 66 months)
• 13 knees had lost >2 of correction at time of latest follow-up
o
• Average initial postop correction for these knees was to 9.4 ± 4.12 (range, 4 to 17 ) of
o o
valgus
• Of knees that lost >2o of correction, 4 subsequently had a total knee arthroplasty
• TKR following HTO
• Expected problems following an HTO may include
• Patellar infera
• Peripatellar scarring (& inability to evert patella)
• Distorted landmarks for proper tibial component orientation
• In many cases, a lateral retinacular release may be necessary
ALTERNATIVES TO HTO
• It takes 6/12 to recover from HTO -> alternatives to HTO are always considered prior to surgery
• Lateral heel wedge to apply valgus moment to knee
• Valgus loading knee brace (unloads medial compartment)
• Steroid injection
• Role of arthroscopy in HTO
• Total knee arthroplasty
159
ORTHOPAEDI UI
Knee Arthrodesis
Indication
• Failed knee replacement - most common

• Uncontrollable septic arthritis with complete joint destruction
• Young patient with severe articular & ligamentous damage
• Neuropathic joint disease
Contra-indication
• Bilateral knee disease

• Ipsilateral ankle or hip disease
• Severe segmental bone loss
• Contralateral leg amputation
Ideal Position
•
o
10-15 flexion
•
o
0-7 valgus
Techniques of Arthrodesis
• External fixation
• Ilizarov technique
• Minimal soft tissue dissection
• Allows for late adjustment
• Allows arthrodesis in presence of active infection
• Intramedullary nailing arthrodesis
• Most reliable for achieving fusion
• 2 stage technique in presence of active infection
• Can insert nail antegrade through piriform fossa or through knee joint
• Cx rates of 20-50%
• Plate fixation
• Medial parapatellar approach
• Excise patella, menisci, cruciate ligaments, & any joint debris
• Distal femur & proximal tibia cut to remove all articular cartilage
• Place femur & tibia in desired position
• Use 2 broad, 8-12 hole AO plates to fit both anteriorly & medially or laterally & medially
• Cut patella into pieces & pack them in any defects about joint margins or secure them to
arthrodesis site with screws
• Close wound in layers & apply a long leg cast
Complications
• Non-union 20%
• Malunion
• Delayed union
• Some postop concerns
• Public attention
160
ORTHOPAEDI UI
• Difficulty riding public transportation

• Difficulty sitting in theaters & stadiums
• Trouble getting up after a fall
Prognosis
• Ellingsen DE, Rand JA - Intramedullary arthrodesis of the knee after failed total knee arthroplasty.
JBJS Am 1994 Jun;76(6):870-7
• 18 knees with intramedullary arthrodesis after failed TKR
• 16/18 united, mean time to union 5.5/12
• High rate of Cx
• 2 AKA (persisting deep infection)
• 1 rod #
• 1 rod migration
Knee Arthroscopy
Indications
• ACL/PCL recon
• Meniscus repair
• Evaluation & Rx osteochondral lesions
• Removal of loose bodies
• Debridement/drainage of knee joint infection
• Evaluation, biopsy, synovectomy of inflammatory conditions
Advantages
• Less invasiveness
• Smaller incisions
• Improved visualisation & access
• Easier rehab
Equipment
• 4-mm 30o scope
Position & Preparation
• Position
• Essential that surgeon position patient -> no difficulty in applying a valgus force to knee
while it remains in full extension
• Without proper positioning, knee will buckle into flexion as a valgus force is applied, &
visualization of posterior horn of medial meniscus will be difficult
161
ORTHOPAEDI UI
• Operative thigh placed against an arthroscopy post or placed in a circular thigh

immobilizer
• End of table may be dropped so that both limbs will dangle at 90
o
• Tourniquet
• Generally not necessary for routine knee arthroscopy
• But often useful when a hypertrophic fat pad requires debridement (eg. chondral injuries)
• Inflow
• May either use gravity system or more preferred pump inflow system
• Pump inflow system
• Be aware excessive inflow pressure may lead to fluid extravasation if
concomitant capsular tear
• Can be partially prevented by applying a firm coband wrap around leg & calf
Portals
• Anteroloateral
• Most important portal, initial site for scope insertion
• Structures that are difficult to see
• PCL
• Anterior portion of lateral meniscus
• Posterior horn of medial meniscus
• Portal placement
• Knee flexed 30 to engage patella into trochlear groove & to keep tension on
o
retinaculum
• Located at least 1 cm above lateral joint line & ~1 cm lateral to margin of patellar
tendon
• Superior portion of meniscus is vulnerable during suprameniscal portal
placement
• Blade should be directed horizontally with blade directed away from patella
tendon
• Once beneath skin, blade can be rotated upwards 90 to gently incise capsule
o
vertically
• Arthroscope sheath with its blunt trocar is inserted through portal & aimed toward
intercondylar notch
• Portal too lateral
• Visualization of intercondylar notch difficult
• Difficult to move leg to figure of 4 position
• Portal too low
162
ORTHOPAEDI UI
• Anterior horn of lateral meniscus may be lacerated or otherwise

damaged
• More likely to enter fat pad
• Portal too high
• Does not permit scope to enter space between femoral & tibial condyles
• Prevents visualization of posterior horns of menisci
• Portal too medial
• Possible penetration of fat pad
• Anteromedial
• For visualization of lateral compartment & instrumentation of medial compartment
• Located 1 cm above medial joint line & 1 cm medial to edge of patellar tendon
• Mark out posterior joint line to ensure that instruments will have adequate access to
posterior meniscus
• Medial meniscus is vulnerable during suprameniscal portal placement
• Posteromedial
• Located in small, triangular soft spot formed by posteromedial edge of femoral condyle &
posteromedial edge of tibia
• ~1 cm above posteromedial joint line & precisely at posteromedial margin of femoral
condyle
• With angled lens, may visualize PCL & posterior horn of medial meniscus
• Superolateral
• Useful viewing dynamics of patellofemoral articulation
• Located just lateral to quadriceps tendon ~2.5 cm superior to superolateral corner of
patella
Complications
• Infection
• Vascular & nerve injury - usually secondary to prolonged tourniquet times
• Neurologic Cx
• Synovitis
• Persistent drainage
• Effusions
• Hemarthrosis
• Deep venous thrombosis
163
ORTHOPAEDI UI

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Sholahuddin Rhatomy, MD

• For every 15 of abduction, there is 10 at gleno-humeral joint & 5 at scapulo-thoracic

• Represented by Global Diagram

• Shoulder motion can be described/modeled using 3 possible systems

INDIVIDUAL JOINT MOTION

• Minimally constrained ball & socket joint

4. Scapular rotators - altered scapulothoracic motion may be related to glenohumeral

• Plane, synovial joint with meniscus

• Synovial joint, meniscus

• Range of glenohumeral to scapulothoracic motion 2:1

TRAUMATIC SHOULDER DISLOCATIONS

• West Point view

• Tangential view of anteroinferior rim of glenoid

• Shows Hill-Sachs lesion

• Affected arm kept at side of body in external rotation

• Prompt reduction Rx of choice

• Key: avoidance of traction

• Posteriorly directed force acting on an adducted & internally rotated humerus

• Static restraints (joint, bone, soft tissue)

• Matsen describes 2 categories of anterior instability

TUBS or “Torn Loose” AMBRI or “Born Loose”

• Often a/w psychiatric condition or alternative gain

Multi-directional Instability (MDI)

• Definition: abnormal amount of excursion of humeral head on glenoid in all directions

Group I Antero-inferior dislocation

• MDI presents as primary instability which is most obvious in 1 direction

Stretch of capsule in continuity

Wide rotator interval

Labrum Bankart tear

Rotator cuff Supraspinatus tear

Type Description Treatment

• Definitive aetiology still not clear

1. Anterior apprehension test

• Adolescent (<20 yrs)

2. Arthroscopic stabilisation (group S)

• Natural history less clear

• This must be continued for at least 1 yr before considering operative intervention

• Can help quantify degree & direction of instability

• Open (gold standard, MDI) vs arthroscopic surgery

Large Hill-Sachs defect

• McLaughlin procedure - infraspinatus muscle is inserted into defect

Rotator Cuff Disease

• A continuum of disease which include

• Accounts for 1/3 of referrals to shoulder clinics

• Neer’s Classification of subacromial impingement syndrome

According to site Articular or bursal side

• Classification of rotator cuff complete tears

• Describe tear by shape = split, L-shaped, reverse L-shaped, crescentic or

Clinical presentation of a tear in rotator cuff

• ‘Grey hair = cuff tear’

• When attempting to do so, whole shoulder girdle elevates

• Obselete, but can show a full or partial thickness tear

• May show a full thickness tear

• Ix of choice for rotator cuff tears

Loss of anterior deltoid function

Management of rotator cuff tears

• Moderate Cuff Tears (1-3 cm)

• Large Cuff Tears (3-5 cm)

Sport & Reconstruction

Sport & Reconstruction

Sport & Reconstruction