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 Instructional Lectures 4
Copyright page 5
Foreword 6
Preface 8
Contents 10
Contributors 12
Part 1: General Orthopaedics, Basic Science and Technology 16
Bone Substitutes in Clinical Work 17
Bone Substitutes 17
Clinical Use of Bone Substitutes 18
Conclusions/THM 21
References 21
Epidemiology and Variability of Orthopaedic Procedures Worldwide 22
Introduction 22
Materials and Methods 23
Data 23
Statistical Analysis 24
Results 24
Discussion 27
References 31
Part 2: Bone and Joint Tumours 33
Cartilage – Forming Bone Tumours 34
Introduction 34
Benign Cartilage Tumours 34
Osteochondroma 34
Clinical Presentation 35
Radiology 35
Differential Diagnosis 35
Histology (Macro- and Micro-) 35
Genetics EXT1 and EXT2 36
Treatment 37
Enchondroma 37
Clinical Presentation 37
Radiology 37
Differential Diagnosis 38
Histology 38
Treatment 38
Multiple Enchondromatosis 38
Juxtacortical (Periosteal) Chondroma 39
Radiology 39
Differential Diagnosis 39
Histology 39
Treatment 39
Chondromyxoid Fibroma 39
Radiology 40
Differential Diagnosis 40
Histology 40
Treatment 41
Chondroblastoma 41
Radiology 42
Differential Diagnosis 42
Histology 42
Treatment 42
Synovial Chondromatosis 42
Radiology 42
Differential Diagnosis 42
Histology 42
Treatment 43
Malignant Cartilage Tumours 43
Malignant Chondrosarcoma 43
Clinical Presentation 44
Radiology 44
Histology 46
Genetics 47
Rare Chondrosarcoma Subtypes 47
Dedifferentiated Chondrosarcoma 47
Mesenchymal Chondrosarcoma 47
Clear-cell Chondrosarcoma 47
Treatment 48
Local Recurrences 51
Prognosis 51
Adjuvant Treatment 53
References 54
Part 3: Paediatrics 56
The Current State of Treatment for Clubfoot in Europe 57
Introduction 57
Epidemiology 57
Aetiology 57
Aetiology of the Congenital Clubfoot 57
Aetiology of the Secondary Clubfoot 57
Pathophysiology of the Clubfoot 57
Bone 57
Muscles and Soft Tissues 58
Diagnosis 59
Presentation 59
Palpation 59
Clubfoot Scoring 59
Dimeglio Scoring System 59
Pirani Scoring System 61
Medical Imaging 62
Radiographs 62
Ultrasound 62
Computertomography (CT)/Magnet Resonance Imaging (MRI) 62
Pedobarography 62
Therapy 63
Conservative Therapy 63
Ponseti Technique for Therapy of Clubfoot 63
Manipulation and Cast Correction in Detail 63
Classical Method of Correction of Idiopathic Clubfoot 68
French Functional Physiotherapy Method 68
Botulinum Type A Toxin 68
Operative Therapy 68
Post-operative Care 69
Therapy of Relapsed, Persistent Clubfoot or Clubfoot in Older Patients 69
Conclusions 71
References 72
Part 4: Polytrauma: Pelvis 75
Management of Pelvic Fractures 76
Introduction 76
Pelvic Anatomy and Stability 76
Sources of Bleeding 77
Classification of Pelvic Ring Injuries 77
Initial Assessment 78
Haemodynamic Instability 80
Mechanical Instability 80
Open Pelvic Fractures 82
Complications 82
Genito-Urinary Injuries 82
Neurological Injuries 84
DVT-PE 84
Post-operative Treatment 84
References 84
Part 5: Shoulder, Elbow, Arm and Forearm 86
The Reverse Shoulder Prosthesis 87
Is There a Need for a Reverse Solution? 87
What Does It Mean – A “Reverse System”? 87
When Is a Reverse System Indicated and What Results Can Be Expected? 88
Cuff-Arthropathy 88
Massive Cuff Tears Without Arthritis and “Pseudo-Paralytic” Arm 88
Acute Fractures 89
Rheumatoid Arthritis 89
Fracture Sequelae 89
Primary Arthritis in Static Posterior Subluxation 90
Revision Surgery 90
Tumour Surgery 90
Do the Results Last? 90
What Is Still Unsolved with the Reverse System? 90
Author’s Rationale for the Use of the Reverse System 91
References 92
Part 6: Spine (incl. Trauma) 93
Spine Injury: Polytrauma Management 94
Introduction 94
Definitions 94
Polytrauma 94
Spine Injury Versus Spine Fracture 95
Neurologic Injury 95
Epidemiology of Spinal Injury in Polytrauma 95
Fracture Classification 95
Timing of Surgery 95
Choice of Surgical Solution 98
Conclusion 98
References 98
Surgical Management of Tuberculosis of the Spine 100
Introduction 100
Aetiology 100
Pathophysiology 102
Diagnosis 104
Indications for Surgery 106
Pre-operative Planning 106
Surgical Technique 106
Non-instrumented Posterior Fusion 107
Anterior Radical Resection and Bone Grafting 107
Debridement (Anterior or Posterior) and Instrumentation 107
Late Deformity 108
Minimally-Invasive Techniques 108
Post-operative Care and Rehabilitation 108
Complications 108
Summary 109
References 109
Part 7: Hand and Wrist 112
Scaphoid Fractures 113
Applied Anatomy 113
Anatomy (Shape, Blood Supply) 113
Ligamentous Attachments 113
Radiological Anatomy (Fig. 1) 114
Aetiology and Classification 115
Mechanism of Injury 115
Classification 115
Diagnosis 116
Clinical Tests 116
Investigations 117
Ultrasound 118
Bone Scan (Fig. 3) 118
MRI Scan 119
CT Scan 119
Treatment of Scaphoid Fractures 120
Cast Immobilization (Fig. 4) 120
Undisplaced Fractures 120
Displaced Fractures 122
Return to Activity 122
Fractures of the Proximal Pole of the Scaphoid 123
Pre-operative Preparation and Planning 123
Operative Technique 123
Considerations 123
Consenting Process 123
Conservative Management 123
Operative Management [70] 124
Open Techniques 124
Palmar Approach 124
Dorsal Approach 124
Observations 124
Percutaneous Technique 124
Post-operative Care and Rehabilitation 125
Complications 125
Malunion 125
Avascularity 125
Non-union (Fig. 6) 126
Bone Grafting (Fig. 7) 127
Outcome 128
Summary 129
Fracture of the Hamate 129
Capitate Fractures 130
Trapezium and Trapezoid Fractures 130
Fractures of the Lunate 131
Triquetrum Fractures 131
Pisiform Fracture 132
References 132
Part 8: Hip 136
Bearing Surfaces 137
Introduction 137
Metal-on-PE 137
Metal-on-Metal 140
Biological Considerations 141
Ceramic-on-Ceramic 142
Oxidised Zirconium (Oxinium) Bearing Surface 142
Ceramic-on-Metal 143
References 143
Hip Pain in the Young Adult 145
Introduction 145
General Principles 145
The Normal Hip Joint 145
Pre-operative Clinical Evaluation 145
Pre-operative Radiographical Evaluation 145
Hip Dysplasia 147
Patho-mechanism in Hip Dysplasia 147
Damage Pattern 147
Classification 147
Radiographic Diagnosis 148
The Natural History of Hip Dysplasia 149
Treatment 149
Results 150
Femoro-acetabular Impingement 151
Patho-mechanism in Femoro-acetabular Impingement 151
Cam Impingement 151
Pincer Impingement 152
Damage Pattern 154
Classification 154
Cam Impingement Types 154
Pincer Impingement Types 154
Radiographic Diagnosis 155
The Natural History of Femoro-acetabular Impingement 155
Treatment 155
Surgical Hip Dislocation 155
Hip Arthroscopy 155
Peri-acetabular Osteotomy 155
Results 156
Summary 156
References 157
Bone Loss Around the Acetabular Component 159
Introduction 159
Classification of Bone Loss 159
Management Strategies for Dealing with Acetabular Bone Loss 160
Local Treatment Methods for Osteolysis 160
Revision with an Uncemented Shell 160
Impaction Grafting and Cemented Revision 165
Surgical Technique 165
Results 165
Allograft and Support Rings and Cages 167
Porous Metal Shells and Augmentation Devices 167
Summary 169
References 169
Part 9: Knee 171
The Uni-Knee: Indications, and Recent Techniques 172
Introduction 172
Concept of the UKA 172
Indications 172
The Stage of Osteoarthritis (Fig. 1) 172
Location and Character of Pain 172
Femoro-tibial Axis 173
The Anterior Cruciate Ligament 174
Pre-operative Mobility 174
Weight 174
Age and Activity Level 174
Contra-indications 174
The “Ideal” Patient 174
Technical Aspects 175
Patient Set-up 175
Incision 175
Tibial Cutting 175
Coronal Plane 175
Sagittal Plane 176
Femoral Preparation 176
Medial UKA 176
Lateral Compartment 177
Prosthetic Stability 178
Definitive Implant 178
Conclusion 179
References 179
Osteotomies Around the Knee 180
Introduction 180
Basic Biomechanics 180
Frontal Alignment 180
Joint Line 180
Sagittal Alignment 181
Patello-femoral Joint 181
Rotational Deformities 181
Patient Selection and Indication 182
Planning 183
Surgical Techniques 185
Tibial Osteotomies 186
Femoral Osteotomies 186
Double Osteotomies 187
Rehabilitation 187
Clinical Results 187
References 189
Total Knee Replacement for the Stiff Knee 191
Introduction 191
Aetiology of Osteoarthritis in Stiff Knees 191
Classical Aetiology of Osteoarthritis in Stiff Knees 191
Post-traumatic Knee Stiffness 191
Haemophilia 192
Anatomical Causes of Knee Stiffness 192
Extra-articular Factors 192
Intra-articular Factors 192
Flexion Contracture 192
Pre-operative Evaluation of Patients for TKR 193
Grading the Osteoarthritic Process and Measuring Deformities 193
Assessing the Type and Severity of Knee Stiffness 193
History of Previous Knee Operations 194
Determining the Patient’s Needs 194
Operative Planning of TKR 194
Flexion Contracture 194
Limitation of Flexion 194
Special Situations Such as Ankylosis or Severe Knee Stiffness 195
Results 195
TKR in Flexion Contracture 195
TKR in Limitation of Flexion 195
TKR in Combined Flexion Contracture and Limitation of Flexion 196
Conclusions 196
References 196
Part 10: Foot, Ankle and Leg 198
Surgical Treatment of Displaced Calcaneal Fractures 199
Introduction 199
Anatomy and Physiology 199
Radiographic Evaluation 199
Classification 200
Treatment of Displaced Calcaneal Intra-Articular Fractures 201
Operative Treatment of Intra-articular Fractures 202
Open Reduction and Internal Fixation 202
Sub-talar Fusion 202
Post-operative Care 202
Results of Treatment 202
Complications 205
Treatment of Calcaneal Fractures by the Ilizarov External Fixation Method 205
Operative Treatment of Extra-articular Fractures 210
Posterior Tuberosity Fracture 210
Anterior Process Fracture 211
Body Fracture (Extra-articular) 211
Medial or Lateral Process Fractures 211
References 212
Forefoot Deformities 215
Introduction 215
Decision-Making in Hallux Valgus Surgery 215
Radiographic Parameters 215
Clinical Parameters 217
Surgical Procedures for Hallux Valgus Deformity 217
Decision-Making in Hallux Rigidus 219
Radiographic Parameters 219
Clinical Assessment 219
Surgical Procedures for Hallux Rigidus 219
Decision-Making in Metatarsalgia Surgery 221
Clinical Assessment 221
Radiographic Assessment 222
Surgical Procedures for Metatarsalgia 222
Decision-Making in Hammer Toe Surgery 223
Clinical Assessment 223
Radiographic Assessment 223
Surgical Procedures for the Treatment of Hammer Toes 223
Conclusion 224
References 224