Thursday, December 22, 2011

General Concepts in Orthopaedic Surgery videos (After AO Foundation)

General Concepts in Orthopaedic Surgery videos (After AO Foundation)
Here's a good collection of Orthopaedic Surgery videos on youtube, for general concepts and surgical videos-

Type B Malleolar Fracture

AO Foundation-Lag Screw

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Sunday, October 30, 2011

Complementary and Alternative Medicine and Osteoarthritis

Symptomatic osteoarthritis (OA) is the most frequent cause of dependency in lower limb tasks with substantial physical and psychosocial disability, reduced quality of life and substantial health care costs.1

Currently, there are no effective disease-modifying remedies for OA. Complementary and alternative medicine therapies have been heavily advertised and increasing numbers of chronic pain patients report utilizing alternative therapies.

Clinical trials and observational studies have provided encouraging evidence that acupuncture and mind-body therapy have benefits for patients with arthritis. This section will review the current body of knowledge on the therapeutic benefits of these types of complementary and alternative medicine on pain and symptom relief in patients with OA to better inform clinical decision-making.

Acupuncture for Osteoarthritis  
Acupuncture, originating in China more than 3,000 years ago, is one of the most popular sensory stimulation therapies. It is an ancient technique of inserting and manipulating fine needles to stimulate specific anatomic points, also known as acupuncture points or meridian points.3

Numerous randomized controlled trials and more than 11 systematic reviews and meta-analyses have examined the clinical efficacy of acupuncture in patients with OA. Evidence from these trials indicates that acupuncture does have some efficacy for relief of pain. For example, an early large, high-quality trial concluded that acupuncture significantly improved pain and function when compared with sham acupuncture or patient education.4 A multicenter randomized controlled trial in Germany found acupuncture plus routine care was associated with marked clinical improvement in patients with chronic OA-associated pain of both the knee and hip.5 After the above study, another large German trial showed that both traditional Chinese acupuncture and sham acupuncture (needling at specified non-acupuncture points) improved pain and functionality in patients with knee OA more than conservative therapy. The effect was assessed by success rates based on WOMAC scores. However, no difference was observed between traditional Chinese acupuncture and sham acupuncture.Similarly, a very recent trial found that traditional acupuncture was not superior to sham acupuncture, but the providers’ style affected both pain reduction and satisfaction with treatment. This finding suggests that analgesic benefits of acupuncture may be partially mediated by the acupuncturists’ behavior and may be enhanced by expectations.7

One systematic review concluded that acupuncture is significantly superior to sham acupuncture in improving pain and function in patients with OA.8 Similarly, the latest Cochrane review with 16 randomized trials indicated that when compared with waiting-list control, acupuncture showed statistically and clinically significant short-term improvements in pain and function for OA. In comparison with sham controls, acupuncture provided small, statistically significant improvements that are of questionable clinical importance.9 In contrast, a meta-analysis observed that sham-controlled trials demonstrated clinically irrelevant short-term benefits of acupuncture, while waiting list-controlled trials had clinically relevant short-term benefits in pain and function, suggesting that placebo or expectation effects may be involved.10  Further work is needed to understand the mechanisms by which acupuncture can improve clinical symptoms.

Overall, there is evidence demonstrating that acupuncture does have short-term benefits for both pain and function in patients with symptomatic OA.

Tai Chi Mind-body Therapy for Osteoarthritis 
Tai Chi is a traditional Chinese mind-body exercise that has recently grown in popularity in the United States. In the past two decades, literature has consistently recognized the potential therapeutic benefits of Tai Chi for a variety of chronic conditions.11 As a complementary mind-body approach, Tai Chi may be an especially applicable treatment for older adults with OA. The physical component provides exercise consistent with current recommendations for OA (muscle strength, balance, flexibility, and aerobic cardiovascular exercise) and the mental component could address the chronic pain state through effects on psychological well-being, life satisfaction, and perceptions of health. These effects may reduce pain, improve function, and slow disease progression and disability associated with OA.

Several randomized, controlled studies have examined the effects of Tai Chi for patients with both knee and hip OA. Hartman and colleagues were among the first to conduct a prospective, randomized, controlled clinical trial to test the efficacy of 12 weeks of Tai Chi for patients with OA. 12 A total of 35 community-dwelling participants were randomly assigned to receive either two one-hour Tai Chi sessions per week for 12 weeks or to usual care. The results of Tai Chi training significantly improved arthritis symptoms, self-efficacy, level of tension, and satisfaction with general health status. 12 In another study, Song and colleagues reported that among 72 patients with knee OA, patients receiving 12 weeks of Tai Chi perceived significantly less pain and stiffness than patients receiving routine treatment. In addition, physical functioning, balance and abdominal muscle strength were significantly improved with the Tai Chi group. 13

In a three-armed, randomized, trial of 152 older patients with chronic symptomatic hip and knee OA, Fransen et al found that, when compared with a waiting list control group, both 12-week Tai Chi classes and hydrotherapy classes provided large and sustained improvements in physical function. All significant improvements were sustained at 24 weeks.14 A six-week group Tai Chi program, followed by six weeks of home Tai Chi training, showed significant improvement in knee pain and physical function compared with an attention control in 41 elderly patients with knee OA. However, the benefits for knee pain scores were not sustained throughout the follow-up detraining period (weeks 13-18).15  A single-blind, randomized trial of 40 patients showed that patients randomized to 12 weeks of Tai Chi exhibited significantly greater improvements in pain, physical function, depression, self-efficacy and health status compared with the attention controls. Patients who continued Tai Chi practice after 12 weeks reported durable benefits in pain and function.16  A recent randomized controlled trial of 82 women with OA suggested that six months of Tai Chi exercise significantly improved knee extensor endurance and bone mineral density and decreased patients’ fear of falling, compared with a self-help education program.17  Similar positive findings of short- and long-term Tai Chi have been well-documented on balance control, flexibility, muscular strength and endurance in the elderly, which have important benefits for patients with symptomatic OA.

Overall, there is evidence suggesting that Tai Chi training may provide an ideal form of exercise for older individuals with symptomatic OA, suffering from pain and poor function.

In summary, the pathophysiological basis of OA is complex and multifaceted and symptomatic OA is heterogeneous. Emerging evidence from clinical trials support that both acupuncture and Tai Chi mind-body therapies may offer effective treatments for OA. Integrative approaches combine the best of conventional medicine and the wisdom of complementary and alternative medicine. These modalities may lead to the development of better disease modifying strategies that could improve symptoms and decrease progression of OA disease.

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Sunday, October 9, 2011

Intramedullary Nailing of Proximal Third Tibial Fractures: Techniques to Improve Reduction

Intramedullary Nailing of Proximal Third Tibial Fractures: Techniques to Improve Reduction
by David J. Hak, MD, MBA
Obtaining and maintaining an acceptable reduction of proximal third tibial fractures can be problematic. Deforming forces acting on the proximal fragment and the spaciousness of the intramedullary canal at this level contribute to this challenge during intramedullary nailing. Several surgical techniques have been developed to address this problem, including the use of a more lateral and proximal starting point, adjunctive plate fixation, blocking screws, semiextended nailing, and most recently the use of a retropatellar portal approach. Familiarity with these techniques is critical to achieve satisfactory results when nailing proximal third tibial fractures.
Intramedullary nailing of simple diaphyseal tibial shaft fractures usually results in near anatomic reduction, as the intramedullary nail fills the intramedullary canal. In contrast, accurate reduction of tibial fractures that are near the proximal metaphyseal junction are notoriously problematic when treated by intramedullary nailing (Figure ).
In the absence of special techniques to achieve and maintain accurate reduction, extra-articular proximal third tibial fractures treated with an intramedullary nail will commonly be malreduced in valgus, apex anterior, and have posterior displacement of the distal segment.
Two main factors complicate the reduction of extra-articular proximal tibial fractures: (1) the deforming forces acting on the proximal tibial segment; and (2) the spaciousness of the intramedullary canal at this level. Flexion of the knee is required to create a traditional intramedullary nail entry site in the proximal tibia. Because of the attachment of the patellar tendon to the proximal fracture segment, apex anterior displacement occurs (Figure ).
Starting Point Location
A more lateral and proximal entry site is helpful to avoid malreduction in proximal tibial fractures (Figure ). Proximally, the medial side of the tibia has been described as a chute that deflects the nail laterally. 4The central axis of the intramedullary canal is most commonly aligned with the lateral tibial eminence. Using a more proximal entry site will achieve a longer segment of nail within the proximal segment and usually place the nail’s Herzog bend completely within the proximal segment, rather than at or distal to the fracture site. Use a more lateral and proximal entrance site to achieve reduction of proximal tibial shaft fractures. Also may use a medially placed universal distractor and placed the interlocking screws with the knee in full extension using a special proximal interlocking jig. 
Adjunctive Plating
Temporary or permanently place a small fragment plate to maintain reduction of the proximal fracture and allow the knee flexion required to insert an intramedullary nail. 
Clinically, both one-third tubular and small-fragment compression plates have been used. Locking plates provide another useful option. A 4- to 6-hole plate is commonly used. The plate can be used temporarily and removed after the nail is successfully inserted and interlocked, or left in place to assist with maintaining the reduction. With the use of unicortical screws, the plate can be positioned along almost any surface. Good screw purchase can usually be obtained with a plate placed anteriorly in the area of thick cortical bone. Alternatively, the plate can be placed along the medial surface. In this case, bicortical screws may be placed from medial to lateral as long as they are anterior to the proximal path of the nail (Figure ).

Pollar / Blocking Screws

Poller or blocking screws to improve reduction in metaphyseal fractures treated with intramedullary nailing. The blocking screws essentially reduce the size of the available nail pathway. Properly positioned screws can prevent malreduction as a nail is placed into a large metaphyseal space. 
Proper placement of blocking screws can be difficult. If they are placed too close to the intended ideal nail pathway, the nail may not be able to be passed, while if they are placed too far from the intended ideal nail pathway, they will not adequately aid reduction of the fracture. Blocking screws can be placed preemptively to prevent known deformity. Alternatively, if a malreduction occurs during placement of an intramedullary nail, the nail can be extracted, the blocking screw(s) placed, and the nail reinserted (Figure ). Intraoperative fluoroscopy is routinely used to assess the optimal position for placement of a blocking screw. 
To prevent apex anterior deformity, a blocking screw is placed from medial to lateral just posterior to the intended ideal posterior location of the intramedullary nail (Figure ).

To prevent valgus angulation, a blocking screw should be placed just lateral to the central axis of the tibia (Figure ). As the nail is passed medial to the locking screw, the deformity is corrected. In contrast, to prevent varus angulation, which is less commonly seen in proximal tibial fractures, a blocking screw should be placed just medial to the central axis of the tibia.
Semiextended Nailing Technique
Use an extended incision, releasing the medial patellar retinaculum to allow subluxation the patella laterally to permit entry site creation and intramedullary nail insertion with the knee in only 15° of flexion. By moving the patella out of the way, the entry site can be obtained with the knee in near full extension, with the awl or opening drill flush up against the trochlear groove of the femur (Figure ).
Retropatellar Portal Technique
Most recently, a retropatellar portal technique has been developed for tibial nail insertion (Figure ). It provides the knee extension benefit of the semiextended nailing technique without the need for an extensile incision. In this approach, a suprapatellar incision is used and the quadriceps tendon fibers split longitudinally. A cannula is used to protect the patellar surface during passage of the entry drill, reamers, and tibial nail. While there are no reported long-term clinical outcomes of this technique, cadaveric investigations have shown it to be a safe technique.


Obtaining and maintaining an acceptable reduction of proximal third tibial fractures can be problematic. Deforming forces acting on the proximal fragment and the spaciousness of the intramedullary canal at this level contribute to this challenge during intramedullary nailing. Several surgical techniques have been developed to address this problem, including the use of a more lateral and proximal starting point, adjunctive plate fixation, blocking screws, semiextended nailing, and most recently the use of a retropatellar portal approach. Familiarity with these techniques is critical to achieving satisfactory results when nailing proximal third tibial fractures.

Medial Malleolar Fractures: A Biomechanical Study of Fixation Techniques

Medial Malleolar Fractures: A Biomechanical Study of Fixation Techniques
by T. Ty Fowler, MD; Kevin J. Pugh, MD; Alan S. Litsky, MD, ScD; Benjamin C. Taylor, MD; Bruce G. French, MD
DOI: 10.3928/01477447-20110627-09


Fracture fixation of the medial malleolus in rotationally unstable ankle fractures typically results in healing with current fixation methods. However, when failure occurs, pullout of the screws from tension, compression, and rotational forces is predictable. We sought to biomechanically test a relatively new technique of bicortical screw fixation for medial malleoli fractures. Also, the AO group recommends tension-band fixation of small avulsion type fractures of the medial malleolus that are unacceptable for screw fixation. A well-documented complication of this technique is prominent symptomatic implants and secondary surgery for implant removal. Replacing stainless steel 18-gauge wire with FiberWire suture could theoretically decrease symptomatic implants. Therefore, a second goal was to biomechanically compare these 2 tension-band constructs.
Using a tibial Sawbones model, 2 bicortical screws were compared with 2 unicortical cancellous screws on a servohydraulic test frame in offset axial, transverse, and tension loading. Second, tension-band fixation using stainless steel wire was compared with FiberWire under tensile loads. Bicortical screw fixation was statistically the stiffest construct under tension loading conditions compared to unicortical screw fixation and tension-band techniques with FiberWire or stainless steel wire. In fact, unicortical screw fixation had only 10% of the stiffness as demonstrated in the bicortical technique. In a direct comparison, tension-band fixation using stainless steel wire was statistically stiffer than the FiberWire construct.
For unstable ankle fractures that involve the medial malleolus, operative treatment is generally recommended. 1–7 Multiple techniques, including bioabsorbable implants, 8 have been used for fixation of the medial malleolus; however, the most common technique as recommended by the Association for the Study of Internal Fixation (AO-ASIF) group uses two 4-mm partially threaded cancellous lag screws placed perpendicular to the fracture line. Stainless steel cancellous screws had up to 24% less pullout force, significantly less torsional and bending strength than a 3.5-mm bicortical screw.
The AO-ASIF group recommends tension-band wiring for small avulsion type fractures of the medial malleolus that are unacceptable for screw fixation as well as for osteoporotic bone. 5 A well-documented complication of tension-band fixation of the medial malleolus is prominent symptomatic hardware, largely due to the subcutaneous nature of the medial malleolus, that often requires a second operation for hardware removal. 2–4,12,13 Replacing stainless steel wire with Fiber-Wire (Arthrex Inc, Naples, Florida) suture could theoretically decrease the incidence of symptomatic hardware and therefore decrease secondary procedures.
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Tuesday, October 4, 2011


The Oxford Shoulder Score (OSS) is a 12-item patient-reported PRO specifically designed and developed for assessing outcomes of shoulder surgery e.g. for assessing the impact on patients’ quality of life of degenerative conditions such as arthritis and rotator cuff problems.
The development of the OSS was driven by demands for a suitable PRO by orthopaedic surgeons who wished to measure the outcomes of their treatments from the patient’s perspective.
The OSS was designed and developed by researchers (within the Health Services Research unit, part of the Division of Public Health and Primary Health Care at the University of Oxford) who also created the Oxford Hip and Knee scores, which are used for assessment of all NHS hip and knee surgeries (approximately 120,000) since April 2009. Designed and developed in association with surgical colleagues at the Nuffield Orthopaedic Centre the OSS has been tested in a surgical context with patients and shown to be reliable, valid and responsive.

Scoring System

Details of the scoring system for the OSS can be downloaded here.

Saturday, March 12, 2011

A technique to remove a jammed locking screw from a locking plate

Bookmark and ShareClin Orthop Relat Res. 2011 Feb;469(2):613-6. Epub 2010 Aug 11.

Case report: A technique to remove a jammed locking screw from a locking plate.

Department of Orthopaedics, Royal Liverpool University Hospital, Liverpool, UK.


BACKGROUND: Locking titanium plates revolutionized the treatment of osteoporotic and metaphyseal fractures of long bones. However as with any innovation, with time new complications are identified. One of the problems with titanium locking plates is removal of screws, often attributable to cold welding of screw heads into the locking screw holes. Several techniques have been described to overcome this problem. We describe a new easy technique to remove a jammed locking screw in a locking plate that is easily reproducible and suggest an algorithm to determine the method to remove screws from locking plates. CASE DESCRIPTION: A 57-year-old man underwent removal of a locking titanium plate from the distal femur. Because the screws could not be readily removed, we used a new technique to remove the jammed locking screws. A radial cut was made in the plate into the locking screw hole and wedged with an osteotome. This released the screw head from the locking screw hole. The screw holes were connected with radial cuts and jammed locking screws were removed in a similar fashion. LITERATURE REVIEW: Instruments used for removal of locking screws, including conical extraction screws, hollow reamers, extraction bolts, modular devices, and carbide drill bits, have been described. However, these do not always work. PURPOSES AND CLINICAL RELEVANCE: Removing screws from locking titanium plates can be difficult. There is no method of implant removal that can be universally applied. Therefore, this new technique and our algorithm may be used when removing screws from locking titanium plates.
PMID: 20700670 [PubMed - indexed for MEDLINE]

Wednesday, January 19, 2011

Sonoma Orthopaedics revolutinise minimally invasive flexible implants

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Least Invasive, By Design
Sonoma Orthopedic Products’ novel fracture fixation devices and instruments revolutionize the way surgeons approach fracture repair.
Less Hardware, Less Pain
Sonoma Orthopedic Products is changing the way that fractures are repaired. Our minimally-invasive surgery requires less hardware and provides greater patient comfort.

Strength Meets Flexibility
Sonoma Orthopedic Products’ proprietary WaviBody™ and ActivLoc™ Technologies offer
least-invasive approaches to fracture repair, enabling direct access, a unique blend of flexibility
and strength, while providing rock-solid fixation.

The Sonoma WRx™ distal radius fracture fixation system provides a least invasive surgical approach for addressing distal radius fractures. Through a single, small incision the Sonoma WRx™ device can be inserted directly into the bone to provide for rigid fixation until the bone heals.
Result: Simple intramedullary access, less soft tissue trauma, minimal pain and potentially, a faster return to normal function for your patients.
The Sonoma CRx™ is the latest innovation in intramedullary clavicle fixation. WaviBody™ Technology allows the implant to take the natural curvature of the clavicle and once actuated, provides rigid support for bone healing. The procedure can be performed through small incisions, while preserving the surrounding soft tissues.
Result: Efficient surgical access, less soft tissue trauma, minimal pain, preservation of clavicle length and potentially, a faster return to normal function for your patients.
Flexible design enables minimally-invasive access to the fracture, unique intramedullary fixation and less hardware.

Customer Service at:

707-526-1335 x241


Sonoma Orthopedics wins first patent

Sonoma Orthopedics has won a patent from the U.S. Patent and Trademark Office for its core technology. 

The maker of minimally invasive bone fixation devices has already received FDA approval for two products – one for mending wrist fractures and another for broken collarbones – and is marketing them in the U.S. and South Africa. Several other medical device makers are nearby, including TriVascular, Medlogics and Direct Flow Medical.