HPI - The healthy 35 years old man, that 3 years ago underwent MVI.
He was diagnosed with a Subcapital fracture RT HIP with Posterior wall of Acetabulum and was treated urgency with 3 cannulated screws and pass one week with ORIF of acetabulum.
Through several month he develop a AVN of head and it was converted to THA RT.
He continued all time with pain of his hip , until he presented with joint sinus rt hip.
One year ago he underwent operation FIRST STAGE OF PJI RT ( the stem was well fixed – and was done ETO) with plate remove.
In his culture was grown MRSA – and he got 3 month DAPTOMICIN treatment.
how proceed with this young patient?
HPI - 59M with 3 years of right knee pain. Due to bilateral knee pain, he uses a motorized cart to get around outside the house and a walker inside the house. He rates his pain as a constant 5/10, worse with walking, and awakens him from sleep.
What type of implant would you expect to use in this patient.
HPI - Chronic low back pain
If performing a THA, what would be your surgical approach?
HPI - Long h/o right hip pain
Right leg always “a little short”
Tried PT / injections / NSAIDS without success
What is your major concern going into surgery?
HPI - Evaluated by rheumatology, dx’d with scleroderma
Started on Methotrexate daily
What would be your surgical approach?
HPI - Retired general surgeon falls of bike suffering a right hip fracture.
What are your treatment next steps?
HPI - Remote history (30 yrs) of left “knee injury”
Left distal 1/3 femur fx 6 years ago
Treated with retrograde IM nail
When performing a TKA in this patient, I would use a:
HPI - Severe bilateral knee pain s/p multiple osteotomies for valgus deformities
When performing Total Knee Arthroplasty in this patient, should the deformity be corrected and how?
HPI - This 62 year old lady mentioned pain with walking stairs and now at rest.
Pain has worsened, despite the following treatments: HA injections, Cortisone injection, Prolotherapy, NSAID, PT.
What further treatment would you recommend?
HPI - Patient is a 43 year old male with 10 year history of left hip pain, groin pain, and restriction in motion. He had hip scope 3 yrs ago which led to no significant improvement. He is married and still plays recreational hockey.
What additional studies do you want to determine treatment?
HPI - Presents with 5 year history of knee pain. Patient walks 10 blocks a day and does not reciprocate stairs. Pain has worsened despite non-operative treatment including NSAIDS, Physical Therapy, and Corticosteroid Injections.
At this time, how would you manage this patient?
HPI - 60 year old female suffered a mechanical fall. She is unable to bear weight on the right leg following the fall.
XRays are shown.
Operated in elsewhere 6 months ago: ORIF
How would you manage this patient?
HPI - Frail 84F. Admitted with LRTI. Fall on medical ward sustaining Grade 1 Open Periprosthetic Tibial Shaft Fracture. Fracture around tip of stem of long stem revision TKR. Revision TKR is Depuy LPS Distal Femoral Replacement with MBT Tibial Tray and Stem. This was implanted 7 years ago for failed distal femoral fracture fixation. Wound was debrided and closed day after injury. Currently in backslab. Referred on for further management. Apologies for poor quality images.
How would you treat this patient?
HPI - The patient had a right hip arthroscopy 5 years ago that included a femoral head re-contouring, os acetabuli resection, and labral reconstruction. Patient has had persistent pain and stiffness ever since that limits his ability to walk distances.
HPI - Factory worker, 3 year history of medial-sided knee pain, previous knee arthroscopy, and debridement of MM and MFC defect which got progressively worse.
What is your surgical management of this patient's knee pain?
HPI - A 34 year old male patient presented for assessment with ongoing left knee pain. He is an avid runner and triathlete and notes that he has been unable to run longer distances over the past 3-4 months due to ongoing pain in the medial aspect of his left knee. He does not recall any associated trauma to the affected knee; his pain has come on insidiously over the past few months and has escalated in severity.
Xrays, Standing Alignment Views, MRI, and arthroscopic images are shown.
The medial femoral condyle demonstrates a full-thickness cartilage defect in the weightbearing portion measuring 18mm AP dimension by 16mm transverse dimension.
Mild degree of chondromalacia in the anterior femur intercondylar region.
No meniscal pathology.
All ligaments intact.
Moderate effusion and debris suggestive of cartilaginous fragments.
After primary arthroscopy revealed the Grade 4 cartilage lesion of the medial femoral condyle, how would you manage this patient?
HPI - The patient underwent a THA 15 months ago at an outside location. Since then he feels pain on the lateral aspect of his hip (greater trochanter area).
His blood results:
CRP: 12.6 mg/dl in November 2016 and 9.9 mg/dl in January 2017.
ESR: 22 mm/h in November 2016 and 21 mm/h in January 2017.
Do you believe this is a prosthetic joint infection?
HPI - The patient has congenital hip disease in both hips (right Hartofilakidis C2, left Hartofilakidis C1). Over the past 2 years she reports progressive right knee pain that is now unresponsive to conservative treatment. She walks with a cane.
HPI - I had done a TKR yesterday and the patient was on an epidural infusion for pain management. 6 hrs post-op, when she was unattended she got up (patient claims to have heard a knock at her room door and wanted to open the door - patient had been drowsy due to the epidural which had a mixture of local anaesthetic and narcotic) from the bed and buckled down with the knee hyperflexed and was on the floor. She had wound dehiscence and I took her to theatre immediately following the fall.
Intra-operatively, I found full thickness dehiscence and MCL substance tear close to tibial insertion was noted. The medial parapatellar tissues were partly ripped and friable. I performed an MCL repair. Since we don't stock implants, there was no chance I could go for a revision to a constrained prosthesis. I was not prepared to wait for a day leaving the wound open and at risk of an infection. I've applied a knee brace.
What is your post-op rehab protocol in this situation?
HPI - 58 yo female with progressive left hip pain and limp for 6 months. No history of trauma or other predisposing factors. No prior treatment.
What is the best treatment for this patient?
HPI - Traumatic paraplegia at T4 level (ASIA A) 12 years ago with progressive spasticity and difficulty with hygiene since the injury.
HPI - A 67 year old patient presents complaining of a 1 year history of pain in his right knee. The pain is aggravated with walking and other activity. He notices an audible click and swelling around the right knee. The patient is 5 years status post a TKA in the same knee.
What is the most probable diagnosis?
HPI - A 18 year old male patient presents with left knee pain.
He suffered trauma to his left knee 1 year ago in an explosion that caused a tibial plateau fracture and extensive burns around the lateral aspect of his left knee and left thigh.
He was treated with an Ilizarov external fixator that left this valgus deformity and a loss of knee ROM.
Physiotherapy has helped the patient gain knee ROM from 0 degrees extension to 70 degrees flexion.
Prior to management, would you order a CT scan of this patient's left knee?
HPI - A 70 year old patient presents with the primary complaint of ongoing left knee pain that has been getting worse over the past 12 months.
The patient states that she has ambulated with a limp since childhood, but has never had surgery or any other treatment up to this point.
She states that she has been taking NSAIDs for the past 12 months which are no longer providing any relief of her knee pain.
She is now having difficulty ambulating due to the pain and has recently started using a cane for support and relief.
HPI - 38M presents with right-sided groin pain of 4 months duration. He states that his pain has been escalating in severity over the past 4 months. He is now limping due to pain on the right side.
The patient underwent ORIF for a posterior column fracture 6 years ago.
He had a right hip resurfacing for post-traumatic arthritis via an anterolateral Hardinge approach 4 years ago.
Based on the information provided, what is the most likely diagnosis?
HPI - 32M presents with medial-sided left knee pain.
He previously underwent a partial medial meniscectomy for an "irreparable tear" at age 18 after a soccer injury.
He returned to his regular activities and has continued playing soccer since his initial surgery, but over the past 3 years has complained of progressive left knee pain, isolated to the medial side of his knee.
He also notes a mild bow-legged deformity of his left leg.
Currently, he rates his pain as 9/10 in severity which is aggravated by activity.
3-foot standing XRays are obtained, which illustrate significant isolated medial compartment arthrosis.
A diagnostic arthroscopy is undertaken - images of the medial and lateral compartments are shown. Significant bipolar lesions of the medial compartment are seen, with full thickness articular cartilage loss in addition to meniscal pathology.
HPI - • 90 female with right hip groin pain x 2 years. Unable to weight bear over last several months
• History of right THA performed in 1996 which provided her with durable pain relief for 18 years
• Initial radiographs demonstrated significant wear and a loose acetabular component with screw breakage
• Given her age, function status and medical comorbidities, she and her husband elected to proceed with nonoperative management
• 3 months after initial presentation, she returned in severe pain after hearing a loud crack in her hip while bending over. Radiographs demonstrated a fracture thru the ischium and suggested pelvic discontinuity
What surgery would you have offered?
HPI - 59 yo iron worker with recalcitrant right knee pain and interested in TKA. CT scan obtained to detail large tibia plateau cyst.....CT scan shows that it breaks through the cortex. patient denies constitutional symptoms or prior knee injury.
Would you obtain further studies prior to TKA?
HPI - Long standing knee OA symptoms - neglected - patient sustained a medial condyle fracture of the right knee 3 months ago which was fixed with interfragmentary screws and an antiglide plate. she wishes to proceed with knee replacement now due to the pain she experiences in both knees.
she is due to have a CT scan of her knees next week before a TKR. I am planning to do the left side first and then the right after 6 - 12 weeks once she is rehabilitated. My plan is to do a PS femur and a stemmed tibia with wedges for the medial tibial plateau defect.
How would you sequence the TKR of each knee?
HPI - Patient complain of hip pain and LOM
Would you rule out infection in this case and how?
HPI - The patient has had hip pain ever since a revision THA 17 years ago. The patient reports the pain has worsened the last 30 day.
How would you treat the left (revised) hip?
HPI - h/o Bipolar 5 years ago for a femoral neck fracture
sustained a fall 6 months after surgery sustaining a periprosthetic fracture. It was fixed with a locking plate, screws, and cerclage wires.
Has not been able to bear weight for last 4-5 months. No h/o fever or recent trauma.
What is your choice for surgical management of this case?
HPI - Inability to weight bear for the last year
Increasing left hip pain over the previous 5 years
Previous left hip surgery in a foreign country > 15 years ago - had mild ongoing hip pain ever since
What type of implant is this?
HPI - 59F with a history of THA revision for loosening, and two subsequent debridements at outside institution complains of L thigh pain and deformity after feeling a snap getting out of bed 3 days ago. Has been non-weight bearing on that side for 1 year per her orthopaedist's recommendations. Started on IV vancomycin 3 weeks ago for "osteomyelitis" of the femur. Lives with husband and daughter. Works as a secretary.
How would you treat the patient at this time (on Vanco for 3 weeks)?
HPI - Had knee revision three years following aseptic loosening
HPI - Symptomatic for last two years. Before that period she managed to compensate her bilateral hip dysplasia.
Which classification is more suitable for this DDH?
HPI - History of injury to right hip joint 15 yrs back.Fixed with Moore's pin
Went into avascular necrosis
How would you remove the screws during surgery?
HPI - Valgus deformity of right knee, corrected with distal femoral varus osteotomy. Postoperative x-rays showed good correction with intact medial hidge. 50 days later, during physical therapy, patient felt acute pain and x-rays revealed fractured medial hidge and loss of correction
How would you treat the patient at this time (Postoperative P1 images below)?
HPI - Patient had simultaneous B/L total knee joint replacement 1 year back.5 months after surgery patient developed pain in left knee joint.ESR and CRP was elevated ESR 90 CRP 35 Xrays showed lysis at the tibial base plate.
Aspirate from bilateral knee joint had polymorps more than 3000WBC/ml with majority of polymorps. Culture sensitivity was positive.
Implant were removed bilaterally. Antibiotic Impregnated articulated cement spacer were inserted using vacomycin inserted cement. Post operative antibiotic were continued for 6 weeks and then stopped. ESR had come down to 45 andCRP had fallen to 20.
Antibiotics were stopped for 3 weeks and B/L knee joint were aspirated which still showed counts more than 2000wbc/ml.culture was negative.
ESR at present is 25 and CRP is 17
No pain and range of motion is 0 to110 degree
Considering final CRP of 17 and ESR of 25 four weeks after stopping antibiotics and 10 weeks post spacer insertion, how would you treat the patient at this time.
HPI - 64 YRS 110 KG MALE PATIENT WAS OPERATED( TOTAL KNEE REPLACEMENT ) FOR RIGHT KNEE PAIN 3 MONTHS BACK. PATIENT DEVELOPED PAIN OVER THE MEDIAL SIDE OF THE KNEE AFTER 15 DAYS. PATIET IS ABLE TO WALK CLIMB STAIRS BUT COMPLAINING OF SEVERE PAIN WHILE GETTING OUT FROM CHAIR OR BED. HE HAD A HABBIT OF CROSSING LEGS WHILE SETTING. WHILE SLEEPING PT KEEPS HIS LIMB IN EXTERNAL ROTATION AND MID FLEXION ( POSITION OF EASE).
HOW TO TREAT THIS UNRESOLVED PAIN
HPI - Trip and fall while walking
Unipolar modular hemiarthroplasty for left subcapital neck of femur fracture in 2013 (double taper highly-polished stem)
How would you treat this injury?
HPI - THA after femoral neck fracture, pain following start of mobilization 5 days after surgery. No subsidence of the stem after WB
How would you treat this intraoperative peri-prosthetic fracture?
HPI - Female 78 years old, with a left TKA revised 3 years ago, tripped on a small stair and fell on her opperated left knee.
How would you treat
HPI - Progressive pain and deformity of knee
Reconstruction of medial tibial defect
HPI - 13 months ago insidious onset of left hip pain which progressively become worse. Sudden deterioration after a sickle cell crisis. Now left hip is Ficat stage III. He started feeling discomfort with his right hip about two months ago. Now right hip is Ficat stage IIA (Precollapse stage)
What is the best combination of bearing surfaces for left THA
HPI - History of injury right knee joint 15 yes back .Treated conservatively .Now presenting with pain on walking
Should TKR be done as a single stage or two staged procedure
HPI - Patient with bilateral knee osteotomy 10 years ago.
Now with knee OA.
HPI - Active male.
Sustained fracture neck femur right hip in Nov 2014 for which optd at another center with Uncemented Bipolar HRA utilizing posterior approach.
Post op had persistent and increasing pain and stiffness right hip and painful weight bearing..
Jan 2015 - Evaluated for the above ...Healed surgical wound .. local temp increased painful movement .... Radiographs s/o progressive heterotopic ossification around hip ... Bone scan +ve for infected prosthesis, ESR and CRP positive. TLC WNL. Alkaline phosphatase - 100.
Underwent Hip aspiration under fluoroscopic guidance .. No pus/ fluid aspirated.
Feb 2015 - Underwent Removal of prosthesis and Debridement with excision of heterotopic mass which was obstructing implant removal. Intra op no pus or any abnormal fluid. Intra op cultures negative
Post op skeletal Traction applied.. indl was totally non compliant with skeletal traction .. surgical wound healed .. Post op given Tab ofloxacin and rifampicin for 06 weeks
Which approach to hip has the maximum risk for heterotopic ossification
HPI - Pain B/L knee joint.left more than right
What should be the treatment plan
HPI - Fall from standing height