HPI - 26 year old male presented with recurrent left ACL rupture a year ago. Prior left ACL reconstruction using allograft, with re-rupture 3-4 months after initial procedure. Pop with acute swelling while jogging during rehabilitation, with persistent pain and instability since then. Unable to jog or do any other activities.
Prior right ACL reconstruction with autograft hamstring eight years ago, no subsequent issues with that knee.
Graft choice (ie auto vs allo)?
HPI - 55Y F, normal weight, recreative sportswoman, last 3 months nonsmoker.
Ski injury in Jan.2015
Feeling of knee instability in some activities.
Plese give me an advice to reconstruct LCA or not!
She is smoker and 55Y old.
What to do...?
HPI - Patient fell and sustained a dislocation of the shoulder 3 weeks ago.
Shoulder reduced on its own.
Non-contact, recreational athlete.
How would you treat this patient?
HPI - 2011 was diagnosed with osteonecrosis of the right knee - no treatment then, kept bearing weight and the pain resolved - till now symptom free - ambulates well, tolerates the pain
HPI - 51 year old LHD male presents one day following an acute injury to his right elbow (non-dominant) when lifting a heavy object. He felt a pop near his elbow and had immediate pain and swelling. On physical exam, he has decreased ROM and significant ecchymosis around the elbow. Radiographs are negative for fracture or dislocation.
How would you treat the distal biceps avulsion in this patient?
HPI - 40 yr old active female with groin pain with activity. No major trauma. Pain getting worse for past few years. All in groin. + pain in groin with FADIR of hip.
Clear hip impingement but with significant protusio / global pincer.
Also with pubic symphysis sclerosis.
LCEA is 49 deg
Classic Contre-coup lesion in posteroinferior acetabulum and posteromedial femoral head.
Hip arthroscopy with acetabular bony resection? Will that lead to futher instability? Labrum will likely be ossified and crappy. Be prepared for labral reconstruction?
Send to open surgeon?
Next step after failing conservative treatement.
HPI - 46F with a chief complaint of right knee pain that began when she heard a pop while performing yoga. She states she subsequently further injured her knee while running and now has a moderate effusion as well as mechanical symptoms. She has been unable to fully extend her right knee, lacking approximately 8 degrees of terminal extension. She is otherwise healthy, enjoys running, and has a BMI of 21.
In a 46 year old avid runner with a medial bucket handle tear, what is the preferred treatment option?
HPI - 10 years ago the patient had taken chemotherapy and radiotherapy and went under a bone marrow transplantation due to ALL diagnosis. He has been totally cured for 10 years and no relapse. He has not been using any immunsuppresive agent since then. (10 years)
What would be your first choice for treatment of this patient?
HPI - Hit flexed right knee on a metal guard rail whilst skateboarding down a hill at 40 km/hr
How would you treat this injury?
HPI - Unclear history of present illness. Fell down 6 weeks ago, pt presented in the hospital 3 weeks after the injury with severe knee effusion. Had a wash out of the knee with the possible diagnosis of knee septic arthritis. He has been d/c home with oral AB. No other details are known from this admission.
Admitted again in our Hospital with ascites and severe knee effusion. Arthroscopic wash out performed again, due to suspicion of a septic knee. Cultures and fluid analysis were negative for infection.
HPI - 52 yo female anethesiologist complains of worsening R hip pain for several months. No specific injury although states that she "tweaked" it on several occasions. She is an avid, competitive tennis player
HPI - 12 month history of pain worse in the last 2 month. Manual worker. occasional amateur soccer player. no history of trauma
What would your next step in management be?
HPI - History of injury knee joint 1year back leading to instability knee joint.presence of lytic lesion incidental finding on x ray
What should be the treatment plan
HPI - 19 year old male football player, Had a atraumatic knee injury June 30,2014, while doing a sudden extension of the knee. He refers pain below the knee cap, when doing flexion and extension. He doesnt tolerate a flexion above 30°. MRI from June 30, 2014 showed a chondrol fracture (see image). He was initially treated with a knee splint, rest, for 4 weeks. After that he was allowed to walk without the splint, open chain excercise, he still have pain while flexing knee over 30°. New MRI shows that the the chondral fracture seems to be still unstable.
What should I do next?
HPI - 25 yo laborer that was dancing at his bachelor party with first-time patella dislocation. evidence of large (approx 2cm)chondral loose body from medial facet with small amount of bone attached to small portion of loose body. TT-TG ratio is normal. In addition to MPFL repair/recon how would you treat the largely chondral fragment with small amounts of bony attachment.
would your treatment include attempted fixation of segments with attached bone, debridement, OATS, microfracture?
would you use bioscrews or acutrax metal screws for any attempted refixation??
deNovo is not available due to insurance restriction.
what would your treatment be for the largely chondral defect with small areas of bony attachment?
HPI - Patient was operated in Feb 2014 for supraspinatus tear right shoulder arthoscopically.Sympotms improved after surgery .At about 3 weeks post op patient developed sudden pain following physiotherapy which subsided after rest for few days.Three months after surgery patient developed severe sudden pain in right shoulder which progressively increased and was also present on rest.
Patient had no fever .
ESR was 50 and crp was negative ,counts were normal
Repeat MRI ON 26 JUNE 14 showed tear of supraspinatus infraspinatus and subscapularis along with signal changes at greater tuberosity.
After course of iv antibiotics symptoms subsided and pain releif was about 70%. After shifting to oral antibiotics pain also increased after about one week .At present pain is about 50%better and movements have slightly improved .
Serial xrays show increasing erosion around greater tuberosity
What is the diagnosis of this post operative complication
HPI - 27 yr F. Multiple knee instability episodes. Many patellar dislocations when teenager. Was a dancer. Has generalized ligamentous laxity.
Had MPFL repair and lateral release 12 years ago. Did not do well after surgery.
Main complaint is instablity.
On exam very lax patella. + apprehension. 4 quadrant excursion.
Failed conservative tx.
+ patella alta
Caton deshamps 1.3
Trochlear dysplasia Dejour type C
+ acl tear
What to do now?
Tibial tubercle tx with distalization and revision mpfl reconstruction
When to reconstruct ACL? Do all one surgery or stage?
HPI - bike vs bus MVA 10 days ago. Was unable to bear weight on the leg immediately after the fall
How would you treat this patient`s ACL?
HPI - 17 year old obese female. BMI 37.2
Playing football with friends. Twisted knee and heard a pop and swelling.
MRI shows acl tear and medial meniscus tear, but standing xrays show significant lateral joint widening.
Full length scanogram shows significant varus alignment.
Difficult to really evaluate posterior lateral corner structures due to obese knee. I did not appreciate any increased external rotation.
What to do for this young pt?
ACL reconstruction alone?
ACL and HTO?
What surgery would you perform?
HPI - 37 year old Male s/p shoulder dislocation and closed reduction.
How would you classify this bony bankart?
HPI - 18 yo following patella dislocation with 12x11mm chondral defect at the median ridge with several chondral loose body fragments. TTTG is 14. In addition to MPFL advancement and lateral release what would be your cartilage restoration technique of choice? Insurance carrier in this region will not pay for DeNovo.
Which cartilage restoration technique would you select?
HPI - Sustained atraumatic patellar dislocation while walking at age 10. Full dislocation, self-reduced. Underwent PT. Sustained another while running. Underwent PT. Then a third dislocation.
What is the next step in treatment?
HPI - 36 year old active male with lateral knee pain. Previous hx of acl recon. Did well with that. Recently started to have lateral knee pain.
Initial arthroscopy did reveal Grade 3-4 lateral joint chondromalacia. Well contained lesions. This was debrided and microfractured. ACL graft was intact.
Continued to have pain. all pain is lateral knee.
Now my Plan is for ACI vs DeNovo.
Full length scanogram films shows mechanical axis falls through the lateral joint. Not terrible but not normal either.
Any indication for distal femoral osteotomy along with cartilage restoration? Stage or do at same time?
Plan of care?
HPI - 58 yr f with lateral knee / leg pain. No trauma. Pain now getting worse.
MRI shows large proximal fibular synovial cyst. Looks like it communicates with the knee joint.
Has failed conservative treatments.
What would be the next step in the management of this patient?
HPI - 40 yo active teacher that sustained proximal hamstring avulsion 7 weeks ago. no sciatic nerve symptoms. Would you use a horizontal incision or vertical incision? Does anyone have experience with the healing rate of the T shaped incision described in Bradley's Article
Evaluation and management of hamstring injuries. Ahmad CS, Redler LH, Ciccotti MG, Maffulli N, Longo UG, Bradley J.
Am J Sports Med. 2013 Dec;41(12):2933-47. doi: 10.1177/0363546513487063. Epub 2013 May 23.
How would you treat this 7 week old injury?
HPI - 18 yo fell on flexed knee skateboarding.
How would you treat this PCL injury with small bony avulsion
HPI - Painless knee crepitus
What is the MRI finding?
HPI - 12 y/o male baseball player presents with his family concern of "limp" when running. No traumatic incident reported. 6 months of symptoms.
What would be your first line of treatment?
HPI - 16 y/o male playing competitive baseball. While up at bat, he completes an aggressive swing and feels a pop above his right hip. He is unable to weight bear on the right leg due to pain.
What initial treatment option would you recommend?
HPI - 38 y/o male smoker, thin build with permanent Rt femoral nerve neurotmesis deep in pelvis s/p GSW >12 months ago with early pelvic infection and Rt acetabular fx now healed and no infection for > 6 months off abx. Patient motivated to achieve more strength and mobility despite achieving independent gait with minimal pain. Knee extension only from IT band and tensor fascia. Functional and stable yet weak gait with intact hamstrings and gastrocnemius. Unable to perform leg raise in supine or sitting position. Neurosurgeon does not plan femoral nerve grafting.
What is your treatment recommendation for this previously active recreational athlete, community leader and businessman?
HPI - 21 year old female with history of recurrent dislocation patella was operated 2yrs back .lateral release ,proximal and distal alignment were performed .intraoperatively there was no dislocation. patient was asymptomatic for one year when after fall she again developed symptoms of recurrent dislocation of patella dwhich takes place in flexion beyond 100 degree
what should be the further treatment plan
HPI - 26 yr old Male with hx of traumatic dislocation in high school. Had open Bankart repair 10 yrs ago. Did well until this year had snowboarding injury and dislocated. Rehabbed for a few months but dislocated again while playing softball.
Continued to with rehab but does have recurrent instability.
MRI and CT show large anterior inferior bony Bankart fragment.
Question is revision Bankart repair (open vs arthroscopic) or think about bony procedure such as LaterJet?
How would you manage this patient?
HPI - Patient presented 3 months after injury with a painful and stiff knee joint. The patient was initially treated with immobilization after suffering from tibial spine avulsion. At three months the cast was removed and patient was put in physiotherapy. Now 6 months after injury patient has full range of motion, no instability, however he continues to have mild pain at night after increased activity.
What should be the treatment for this injury at this time?
HPI - H/O fall 6 months back leading to injury right kee joint.patient is having recurent episodes of knee giving way with painful episodes
what is best treatment optionin 15.5 year old
HPI - Patient presented with anterior dislocation right shoulder joint
Closed reduction done same day .post reduction Xray satisfactory
Serial Xray show inferior sublaxation increasing
MRI shoulder done at 3 weeks shows posterior sublaxation and rotator cuff tear
What would be your next step in treatment for this patient?
HPI - 43 yr old male with shoulder pain. Hx of cuff repair 4 years ago.
HPI - 62yo female, no sports, retired. After fall in hiperflexión of hip with extended knee, presents pain, haematoma in posterior thigh
What treatment would you choose?
HPI - 38 yr old very active with anterior knee pain for many years. Was told it was nothing by many orthopods.
Clear valgus alignment
Imaging shows patella alta with increased TTTG distance. Lateral patella facet and lateral trochlea chondral damage.
Decided to proceed with arthroscopy after initial trial of non op treatment.
What should be the next step of treatment?
HPI - 17 yr female. Pulled "muscle" she was told when she was younger running track. Presented to me with hip pain.
HPI - Trauma right lower limb one and half year back.Interlocking tibia done.gradually patient started developing instability of knee joint.fracture tibia has united
When should ACL be repaired?
Will tibial nail or screws interfere with hamstring graft and interference screw
HPI - 69 male complicated r shoulder hx.
Initial proximal humerus fx. Had ORIF. Did ok but developed impingement. Eventually had removal of hardware and rotator cuff repair.
Then had p acnes infection. Was treated with IV abx protocol and shoulder wash out twice.
Now presents to me with shoulder pain.
MRI shows large cysts in humeral head.
Aspiration showed continued p acnes infection.
I elected to perform two staged reverse tsa.
Placed abx spacer. Pain has improved significantly.
Infection labs have always been normal.
Now do I:
Plan for placement of reverse while obtaining frozen, but will p acnes show up?
Place reverse along with calcium sulfate abx beads?
How to determine if p acnes infection has been irradicated?
HPI - right knee pain for 6 months.
What is your planned surgical treatment
HPI - Knee pain at last 3 months
No pain at rest
No signs of inflammation
What is the best treatment?
HPI - pain and repeated swelling post knee since a year. no trauma. repeated aspiration have been done of the cyst in other clinics.blood picture normal
arthroscopic meniscal debridement evacuation of cyst thru knee.or bakers cyst excision thru posterior approach
HPI - 37 yr old very active female with knee pain.
What are further options?
HPI - 32 yr old male with hx of "shoulder dislocation" when in high school during football. Not aware if posterior or anterior. Was scheduled to have surgery back then but choose not to. Did well for many years but recently started to develop locking and catching and occational shoulder pains, otherwise very functional.
Options for this patient?
HPI - 25 yo female with noncontact twisting injury to left knee while doing step aerobics. MRI shows isolated ACL tear. XR's show normal tibial slope. Patient wishes to return to aerobics.
At what degree of knee range of motion would you secure your ACL graft in a patient with knee recurvatum and systemic hyperlaxity
HPI - 29 yr female with anterior knee pain for many years. Saw orthopod who scoped her without picking up on patella alta. Had "crabmeat" condromalacia according to op note which he treated with heat probe.
Now presents to me a year later with extreme pain much worse than before surgery.
HPI - 29 yr of female with hip pain for many years. Right worse than left
How would you treat this patient's RIGHT hip?
HPI - Mild hip pain since 3 month, not affecting her activity
What is the best treatment option