European Instructional Lectures (eBook)

Professor George Bentley is Professor of Orthopaedic Surgery and Director of the Institute of Orthopaedics, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, Middlesex, HA 4LP, UK. He is Director of Clinical Studies, Clinical Training and Research Advisor. Furthermore, he is Honorary Consultant Orthopaedic Surgeon, Royal National Orthopaedic Hospital Trust, Stanmore. He is Past President of EFORT, Chairman Awards and Prizes Com., and Chairman Scientific Publ. Com.

European InstructionalLectures 1
Part IGeneral Orthopaedics 12
Necrotising Fasciitis 13
Definition 13
Aetiology 13
Epidemiology 13
Risk Factors 14
Pathophysiology 14
Diagnosis 14
Clinical Presentation 15
Laboratory Evaluation 15
Radiologic Evaluation 16
Histologic Evaluation 16
Diferential Diagnosis 16
Management 17
Surgical Debridement 17
Antibiotic Therapy 17
Supportive Therapy 18
Adjunctive Therapies 18
Outcome 18
Our Experience 19
Conclusions 19
References 23
Trauma: Non-Union: New Trends 25
Introduction 25
Low Instensity Pulsatile Ultrasound (LIPUS) 25
Magnetic Field Induction 26
Growth Factor Treatment 26
Stem-Cell Therapy 28
References 28
Part IIBone and Joint Tumours 30
Bone Tumours: Work Up 2009 31
Introduction 31
Primary Evaluation 31
X-Ray, CT 31
MRI 33
Ultrasound 36
Scintigraphy 38
PET, PET/CT 39
PET 39
PET/CT 39
Comparison of the Different Methods and Summary 39
Monitoring Response to Therapy 41
Follow-Up Monitoring 42
Soft Tissue Sarcoma 42
Adult Osteosarcoma 42
Adult Ewing-Sarcoma (incl. PNET) 42
References 43
Diagnosis and Treatment of Soft Tissue Sarcomas 45
Introduction 45
Clinical Features 45
Diagnostic Algorithm and Imaging of the STS 46
Biopsy and Histological Examination 47
Staging and Prognostic Factors 49
Local Control Rate and Survival 50
Other Factors Influencing Survival 51
Surgery of STS 51
Surgical Margins 51
Reconstructive Surgery in Deep STS 52
Treatment of Local Recurrent Tumour 54
Surgery of Lymph Node and Other Distant Metastases 54
Radiotherapy 54
Chemotherapy 55
The Effectivity of Different Drugs in the Treatment of STS 56
Conclusions 56
References 56
Part IIIPaediatrics 59
Management of Lower Limb Deformities 60
Introduction 60
Advances in Deformity Correction 60
Guidelines for the Treatment of Congenital Deformities of the Lower Extremity 63
Congenital Femoral Deficiency (CFD) 63
Fibula Deficiency 65
Tibial Hemimelia 66
Lengthening of Short Stature Patients 66
Prevention of Complications 66
In Conclusion 66
References 67
Total Hip Replacement in the Congenitally Dislocated Hip Using the Paavilainen Technique..1 68
Patients and Methods 68
Results (Table .1.) 70
Discussion 71
References 71
Part IVTrauma 73
Operative Strategy for Fracture-Dislocation of the Elbow 74
Introduction 74
Diagnostic Tools 74
Conventional Imaging 74
Computed Tomography 75
Evidence-Based Medicine? 77
Injury Mechanism 77
Fracture Fixation 77
Surgical Approaches 77
Coronoid Process 77
Radial Head 79
The “Terrible Triad” 80
Trans-Olecranon Dislocation 80
The Role of Hinged External Fixation 81
References 81
Fractures of the Scaphoid: Diagnosis and Management 84
Foreword 84
Diagnosis 84
Differential Diagnosis 85
Classification 85
Treatment 85
Transcaphoid-Perilunar Dislocations 87
Scaphoid Fractures in Children 87
“Old” Fractures 88
Bone Union 88
Rehabilitation 88
Aknowledgements 88
References 88
Part VSpine 90
Treatment of Thoraco-Lumbar Fractures 91
Introduction 91
Epidemiology of Spinal Injuries 91
Initial Management of Polytrauma Patients with an Associated Spine Injury 91
Thoraco-Lumbar Trauma Imaging 92
Classification Systems 93
Evolution of Classification Systems 93
Denis Classification (1983) 93
The Load-Sharing Classification (1994) 93
The AO Classification (1994) 93
The Thoraco-Lumbar Injury Classification and Severity System (TLICS, 2005) 93
Non-Surgical Treatment of Thoraco-Lumbar Fractures 95
AO Types A1 and A2 95
Burst Fractures (AO Type A3) 95
AO Fractures Type B and C 95
Surgical Treatment 96
Surgical Treatment for Fractures with Neurologic Deficit 96
Surgical Treatment for AO Type A and B Fractures Without Neurologic Deficit 96
Less-Invasive and Recent Surgical Techniques 97
Conclusions 99
References 99
The Rheumatoid Cervical Spine 101
Introduction 101
Pathophysiology 101
Natural History 101
Clinical Presentation 103
Radiologic Work-Up 104
Treatment of Cervical Rheumatoid Arthritis 106
Conservative Treatment 106
Surgical Treatment 106
Conclusions 109
References 109
Part VIUpper Limb 111
Partial Rotator Cuff Ruptures 112
Partial Rotator Cuff Rupture 112
Anatomy of the Supraspinatus Footprint 112
Gross Anatomy 112
Microscopic Anatomy 112
Blood Supply to the Rotator Cuff 112
Local Biomechanics 113
Definition and Classification 113
Incidence 114
Pathogenesis 114
Natural History 114
Clinical Presentation 114
Diagnostic Imaging 115
Diagnosis at Surgery 116
Treatment Options and Indications 116
Conservative Treatment 116
Operative Treatment 116
Arthroscopic Assessment 117
Arthroscopic Debridement Alone 118
Arthroscopic Debridement and Sub-Acromial Decompression 118
Cuff Repair 119
Conclusions 120
References 120
Massive Tears of the Rotator Cuff 123
Introduction 123
Anatomy and Biomechanics 123
Evaluation and Classification 124
Treatment 125
Conservative Management 125
Isolated Débridement and Decompression 125
Direct Cuff Repair 126
Partial Cuff Repair 126
Combination of Cuff Repair and Tissue Substitution or Augmentation 127
Cuff Reconstruction with Tendon Transfers 127
Arthrodesis and Arthroplasty 129
References 129
Part VIIHip 132
Hip Resurfacing 133
Introduction 133
The Birmingham Hip Resurfacing 133
Results, Problems and Solutions 134
Femoral Failures 134
The Birmingham Mid-Head Resection 135
Metal Ion Elevation 137
Pseudotumours 137
Bearings Other than Metal-On-Metal for Resurfacing 139
Conclusion 141
References 141
Part VIIIKnee 143
Total Knee Arthroplasty in Extra-Articular Deformities 144
Introduction 144
Extra-Articular Correction 144
Intra-Articular Correction 145
Effects of Intra-Articular Femoral Correction 146
Effects in the Coronal Plane 146
Effects in the Sagittal Plane 147
Effects in the Transverse Plane 147
Effects of Intra-Articular Tibial Correction 147
Effects in the Coronal Plane 147
Effects in the Sagittal Plane 148
Effects in the Transverse Plane 148
Pre-Operative Planning 148
Surgical Technique 149
Extra-Articular Correction 149
Intra-Articular Correction 150
Extra-Articular Deformity of the Femur 150
Extra-Articular Deformity of the Tibia 150
Soft-Tissue Balancing 151
The Role of Navigation 153
Conclusions 155
References 155
Unicompartmental Knee Arthroplasty 157
Articular Cartilage 157
The Knee 158
Unicompartmental Knee Replacement 159
Tibiofemoral 159
History 159
Indications 159
Introduction 159
Principles 160
Soft Tissues 160
Bony Alignment 161
Restoration of the Joint Line 161
Medial Tibiofemoral UKR 161
Lateral Tibiofemoral UKR 161
Conclusion 162
Patellofemoral Joint 162
Concluding Remarks 162
References 162
Isolated Patellofemoral Osteoarthritis 164
Biomechanics 164
Aetiology 164
Extensor Mechanism Causes 165
Patella Alta 165
Patellar Tilt and Patellar Shift 165
TT-TG Distance/Q Angle (Extensor Mechanism Alignment) 166
Dysplasia of the Patella 167
Trochlear Dysplasia 167
PF Dislocation 167
No Extensor Mechanism Causes 169
Trauma 169
Obesity 169
Gender 169
Genetic 169
Clinical Presentation 169
Evaluating the Outcome of Patellofemoral Disorders 170
Radiology and Imaging 171
X-Ray 171
CT Scan 172
MRI 173
Treatment 173
General Considerations 173
Non-Operative Management of Patellofemoral Arthritis 173
Surgical Procedures 173
Role of Arthroscopy 173
Soft-Tissue Re-Alignment of the Extensor Mechanism 173
Isolated Lateral Retinacular Release 174
Lateral Patellar Facetectomy 174
Proximal Soft-Tissue Re-Alignment 174
Surgery to the Patella 175
Patellar Thinning 175
Patellar Osteotomy 175
Patellectomy 175
Autologous Chondrocyte Implantation 176
Osteotomies of the Tibial Tubercle 177
Anterior Tibial Tubercle Transfer 177
Medial Tibial Tubercle Transfer 178
Distal Tibial Tubercle Transfer 179
Patellofemoral Arthroplasty 179
Total Knee Arthroplasty 180
Overview 181
References 181
Part IXFoot and Ankle 186
Achilles Tendinopathy 187
Introduction 187
Anatomy 187
Histology 187
Physiopathology 188
Metalloproteases 189
Clinical Examination 189
VISA-A 189
Management 190
Conservative 190
Surgical Procedures 191
Conclusions 192
References 192
The Painful Flatfoot 196
Introduction 196
Anatomy and Biomechanics of the Tibialis Posterior Muscle 196
Epidemiology 197
Patho-Mechanism of the Adult Flatfoot 197
Clinical Examination 197
Imaging 198
Classification 199
Treatment 199
Stages I and II: The Flexible Foot 201
Stage I 201
Stage II 201
Stages III and IV: The Rigid Foot 202
Stage III 202
Stage IV 202
Rehabilitation 202
Conclusion 202
Take Home Pearls 203
References 203