Lower Extremity Lower Extremity Orthopedic ReviewOrthopedic Review

WAPA Winter Conference

January 30, 2013

Seattle, Washington

Fred Huang, MD

Valley Orthopedic Associates

A Division of Proliance Surgeons, Inc.

What We Aren’t Covering

Lumbar spine and foot conditions Musculoskeletal infections & tumors Inflammatory arthritis (i.e. rheumatoid

arthritis)

Great reference: Miller’s Review of Orthopedics

Ankle Sprains

Most often an inversion injury

Lateral ligaments most commonly injured: Anterior talo-fibular ligament Calcaneo-fibular ligament Posterior talo-fibular ligament

Grades 1, 2, and 3

Ottawa Rules for imaging

Source: www.intermountainhealthcare.org

Source: www.bodyflow.com.au

Ankle Sprains

Grades 1 and 2 treated with RICE R = rest I = ice C = compression E = elevation

NSAID’s, taping/bracing, and PT

Grade 3 injuries sometimes immobilized for several weeks (walking boot vs. cast)

Some grade 3 injuries treated operatively

Source: www.bodyflow.com.au

Achilles Tendon Ruptures

Usually occur in patients 35-50 years old “Somebody kicked me in the back of the leg” Tears are about 5 cm above the calcaneal attachment Diagnosed with a positive Thompson test

Squeezing the calf muscle produces no ankle plantar flexion

Cast treatment: reliable but slightly higher risk of subsequent re-rupture

Surgical treatment: reduces risk of re-rupture but introduces surgical risks

Non-operative with early motion/rehab best?

Ankle Fractures

Lateral malleolus fracture

Bimalleolar fracture - unstable

Trimalleolar fracture - unstable

Syndesmosis injury i.e. disruption of ligaments that

stabilize the distal tibio-fibular joint

“High” ankle sprains

Lateral Malleolus Fracture

If minimally displaced and no major ligament injury, cast treatment sufficient (stress view important)

If significantly displaced or unstable, treat with ORIF (open reduction and internal fixation)

Maissoneuve Injury

Involves ligamentous injury at ankle with bony injury of proximal fibula

Ankle swelling medially (deltoid ligament injury) and in the distal leg (syndesmosis ligament injury)

Proximal fibula fracture not seen on ankle films – must order full length tibia/fibula films

Maissoneuve Injury

Stress views helpful Surgical treatment always Syndesmosis stabilization

with 1 or 2 screws Screws will break or

loosen when full activities allowed due to motion at distal tibio-fibular joint

Screws often removed electively prior to resumption of full activities

Other Ankle Conditions

Peroneal tendon tears – posterolateral pain/swelling Most often degenerative – longitudinal tears in the peroneus brevis Peroneal tendon subluxation – often associated w/ trauma (SURGERY)

Ankle arthritis Often post-traumatic. Can also be inflammatory or just primary DJD. Fusion (versus arthroplasty?)

Lateral process fractures of the talus Frequently occur in snowboarders Forceful ankle dorsiflexion with eversion and axial loading Treated with excision vs. ORIF (or cast if non-displaced)

Common Knee InjuriesCommon Knee Injuries

Meniscal TearsACL TearsMulti-ligament InjuriesTibial Plateau Fractures

Age Related Injury Patterns

Teenagers Ligament and meniscal tears Patellar dislocations Growth plate injuries

Adults Ligament and meniscal tears Some tibial plateau fractures

Elderly More tibial plateau fractures

Patello-femoral Pain

Frequent cause for ANTERIOR knee pain Worsened by squatting, stair-climbing, and lunges Often associated with anterior knee crepitus

(chondromalacia patella) Usually no joint line tenderness & negative McMurray’s Effusions possible, but rare MRI’s often “normal” Treatment consists of activity modification, formal PT,

NSAID’s, weight loss, and occasional steroid injections Patellofemoral rehab should include hip strengthening

Growth Plate Fractures

Growth plate injuries <15 for

females <18 for males

Not always readily apparent on initial x-rays

Patellar Instability

Almost all patellar dislocations are lateral and in teenagers

Medial patellofemoral ligament fails

Surgical treatment for recurrent instability and/or loose bodies

Reduce by extending the knee +/- direct pressure at the lateral patella

Meniscal Tears

Clinical Symptoms Swelling Catching +/- locking Difficulty with pivoting and squatting

Physical Exam Findings Effusion Joint line tenderness Positive McMurray’s maneuver

Meniscal Tears

Arthroscopic surgery if mechanical symptoms present

Degenerative tears: associated with minimal or no trauma

Many degenerative tears associated with DJD & thus not operated on

Source: www.opsmart.com

Source: www.stoneclinic.com

Types of Ligament Injuries

ACL very common

MCL most common with ski injuries Usually treated non-operatively with brace

Combination injuries (ACL w/ MCL most common, but any combo possible)

PCL involved frequently in multi-ligament injuries

ACL Tears

Twisting on a planted foot

Unable to continue sporting activity

Effusion within 1-2 hours

Lachman testIncreased anterior tibial translation at 20 degrees of knee flexion

Source: Knee Ligament InjuriesThe Staywell Company, 2001

ACL Tears - Treatment

Non-operative treatment (Brace?)

Surgical treatment Timing of surgery Graft options: autograft versus allograft Associated procedures: meniscal repair vs.

meniscectomy, cartilage procedures

Multi-ligament Knee Injuries

Higher energy mechanism than ACL tears

Knee (tibio-femoral) dislocation?

Critical to assess neurovascular function: Motor/sensory function at the ankle/foot Palpable distal pulses? (Popliteal artery injury?) Consider further vascular testing (CT-angiogram

vs. arterial ultrasound or arteriogram)

Multi-ligament Knee Injuries

More frequently treated operatively than isolated ligament injuries

Allograft tissue almost always used

Rehab more difficult, post-op stiffness common, and return to sports less likely

Multi-ligament Knee Injuries

Don’t forget the “5th” knee ligament ACL, PCL, MCL, and LCL = “big 4” Postero-lateral corner PLC injuries PLC is a complex collection of soft tissue structures

between the lateral femur, proximal fibula, and proximal tibia

Most often injured in conjunction with the PCL and/or LCL (i.e. rarely an isolated injury)

PLC injuries result in rotational instability

Tibial Plateau Fractures

Wide spectrum of injury patterns

Medial and/or lateral; tibial eminences (cruciate injury)

Split and/or depressed fragments

Increased cartilage injury means post-traumatic arthritis more likely

Tibial Plateau Fractures

CT scans helpful in defining the fracture

Anticipate other injuries (meniscal tears, ligament tears, arterial or neurologic deficits)

Tibial Shaft Fractures

If aligned well, often treated initially with a long leg cast

Open fracture, inability to maintain alignment, polytrauma, and patient preference are all reasons why operative treatment frequently utilized

Tibial Shaft Fractures

Benefits of operative treatment: Shorter immobilization time No long leg cast = less atrophy &

stiffness Avoidance of multiple cast adjustments

and frequent X-rays

Surgical Treatment options: Medullary rodding Plating External fixation

Tibial Rodding

Can be done in a “closed” fashion

Highly dependent on fluoroscopy

Potential for persistent anterior knee pain

Diagnosis of Knee DJD

3 compartments of the knee: 1. Patello-femoral 2. Medial tibio-femoral 3. Lateral tibio-femoral

Physical Exam: Stiffness Deformity (varus = bow-legged,

valgus = knock-kneed) Effusions common

Knee DJD – Radiographic Findings

Hallmarks of DJD 1. Loss of cartilage thickness 2. Bony sclerosis 3. Osteophytes (bone spurs) 4. Bone cysts 5. Joint subluxation

Weight-bearing radiographs a must 1. Compare with other side 2. Flexed view important

Knee DJD – Treatment Options

Standard treatments: 1. NSAID’s and acetaminophen 2. Glucosamine/chondroitin 3. Activity modification & wt. loss 4. Intra-articular steroid injections 5. Visco-supplementation (Synvisc) 6. Unloader braces 7. Neoprene sleeves 8. Osteotomy surgery 9. Knee replacement –

unicompartmental versus total knee replacement

Varus Knee DJD – Proximal Tibial Osteotomy

Intermediate solution that improves pain and function usually for < 10 years

Allows for continued impact activities

Associated with a longer recovery time (to allow for healing of osteotomy)

Does not “burn bridges”

Knee DJD – Total Knee Replacement

Reliable solution that improves pain and function usually for >10 years

Does not allow for continued impact activities

Intensive therapy and exercises critical post-op to establish ROM

New interest in multi-modal pain management, smaller incisions, and accelerated rehab

Total Knee Replacement Risks

DVT/PE Infection Post-operative stiffness Early component

loosening or failure

Hip Fractures

Common in the elderly Low energy trauma Osteoporosis

Higher energy injuries in adults – MVA’s, fall from heights

Variety of fractures and treatment options

Femoral Neck Fractures

If non-displaced or impacted in a stable position, screw fixation suitable

If displaced not likely to heal, thus usual treatment is an endoprosthesis

(i.e. hemi-arthroplasty)

Some patients are managed with total hip arthroplasty

Intertrochanteric Hip Fractures

Occur distal to the femoral neck, where the blood supply is very good

Unlike femoral neck fractures, non-union is not usually a concern

Intertrochanteric Fracture Fixation

Fixation usually stable enough to allow for early full weight-bearing

Some surgeons prefer rods for IT fractures in the elderly – protects the entire length of the femur

Femoral Shaft Fractures

Most are treated with medullary rods with interlocking screws

Percutaneous technique reduces soft tissue trauma to gluteal muscles and facilitates recovery

Subtrochanteric Femoral Stress Fractures Associated with Bisphosphonates

Fosamax, Boniva, Actonel, Zometa

Decrease osteoclast activity, but also impair osteoblast activity

Better bone density, but bone architecture is less “coordinated”

Osteonecrosis of the jaw and stress fractures of the proximal femoral shaft – ask about jaw and thigh pain

Stop drug if on it > 3-5 years

Alternatives: Forteo (PTH) or Prolia?

Diagnosis of Hip DJD

Most commonly causes GROIN pain Can also cause lateral hip pain and/or buttock pain Some even get referred pain to the ipsilateral thigh/knee

Symptoms worse with weight-bearing and better with rest

Physical Exam: Reduction of motion, especially internal rotation Pain worsened with internal rotation of the hip when flexed Possible shortening of the affected extremity

Hip DJD – Radiographic Findings

Hallmarks of DJD 1. Loss of cartilage thickness 2. Bony sclerosis 3. Osteophytes (bone spurs) 4. Bone cysts

Hip DJD – Treatment Options

Standard treatments: 1. NSAID’s and acetaminophen 2. Glucosamine/chondroitin 3. Activity modification 4. Intra-articular steroid injections 5. Total hip replacement

Hip DJD – Total Hip Replacement

Reliable solution that improves pain and function, but not designed for impact activities

Posterior approach: Higher dislocation risk More familiar anatomy

True anterior approach: Lower dislocation risk Learning curve, special equipment Quicker recovery (1st 6 months)

Total Hip Replacement Risks

DVT/PE Infection Leg length discrepancy Dislocation Component loosening or failure Intra-operative fracture

Miscellaneous Hip Conditions

Trochanteric bursitis Lateral hip pain, worsened with direct pressure (side-lying) PT (stretching), NSAID’s, and cortisone injections

Hip labral tears Often degenerative, an early sign of DJD Traumatic injury – role for arthroscopic surgery – probably the best

results

Femoro-acetabular impingement (FAI) Early stage of DJD as well Open versus arthroscopic debridement

Occult Femoral Neck Fracture

If films negative but exam positive --> MRI (or bone scan) helps to make the diagnosis

Should be treated

“semi-urgently”

Screw fixation usually adequate since fracture is non-displaced