1. Lower Extremity Orthopedic Review WAPA Winter Conference January 30, 2013 Seattle, Washington Fred Huang, MD Valley Orthopedic Associates A Division of Proliance Surgeons, Inc.

2. 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

3. 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

4. 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

5. 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?

6. 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

7. 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)

8. 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

9. 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

10. 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)

11. Common Knee Injuries  Meniscal Tears  ACL Tears  Multi-ligament Injuries  Tibial Plateau Fractures

12. 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

13. 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

14. Growth Plate Fractures  Growth plate injuries  <15 for females  <18 for males  Not always readily apparent on initial x-rays

15. 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

16. Meniscal Tears  Clinical Symptoms  Swelling  Catching +/- locking  Difficulty with pivoting and squatting  Physical Exam Findings  Effusion  Joint line tenderness  Positive McMurray’s maneuver

17. 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

18. 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

19. ACL Tears  Twisting on a planted foot  Unable to continue sporting activity  Effusion within 1-2 hours  Lachman test Increased anterior tibial translation at 20 degrees of knee flexion Source: Knee Ligament Injuries The Staywell Company, 2001

20. 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

21. 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)

22. 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

23. Multi-ligament Knee Injuries  Don’t forget the “5 th ” 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

24. 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

25. Tibial Plateau Fractures  CT scans helpful in defining the fracture  Anticipate other injuries (meniscal tears, ligament tears, arterial or neurologic deficits)

26. 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

27. 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

28. Tibial Rodding Can be done in a “closed” fashion Highly dependent on fluoroscopy Potential for persistent anterior knee pain

29. 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

30. 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

31. 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

32. 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”

33. 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

34. Total Knee Replacement Risks  DVT/PE  Infection  Post-operative stiffness  Early component loosening or failure

35. 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

36. 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

37. 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

38. 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

39. Femoral Shaft Fractures Most are treated with medullary rods with interlocking screws Percutaneous technique reduces soft tissue trauma to gluteal muscles and facilitates recovery

40. 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?

41. 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

42. Hip DJD – Radiographic Findings  Hallmarks of DJD  1. Loss of cartilage thickness  2. Bony sclerosis  3. Osteophytes (bone spurs)  4. Bone cysts

43. 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

44. 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 (1 st 6 months)

45. Total Hip Replacement Risks  DVT/PE  Infection  Leg length discrepancy  Dislocation  Component loosening or failure  Intra-operative fracture

46. 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

47. 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