options

Indications

RA 

OA 

AVN 

Contra-indications

Infection

Charcot

Paralysis of deltoid

Torn rotator cuff

Insufficient glenoid bone stock

Indications 

1. Significant functional impairment

2. PIPJ contracture

- originally thought to intervene early

- Macfarlane showed residual FFD always about 30^o

- may need to release  check rein ligaments / accessory collateral ligaments

3. MCPJ contracture >30^o

4. Trigger fingers

- must do limited fasciectomy 

Anatomy

Osseous canal between talus and calcaneum

- interosseous talo-calcaneal ligament

- cervical ligament

- joint capsule

- nerve endings / arterial anastomoses

Aetiology

Flat foot / overpronation

Inversion / sprain

Pathology

Basic Concepts

Proximal tibia

- gastrocnemius local muscle flap

- gracilis free muscle flap if gastroc damaged

Middle tibia

- soleus local muscle flap

- gracilis free muscle flap

Distal tibia

- posterior tibial fasciocutaneous local flap

- gracilis free muscle flap

Epidemiology

Usually young patients

- 15 - 40

15% compound

Aetiology

High velocity injury

- MBA

- MVA

- pedestrian v car

- fall from height

Emergency Managment

EMST principles

- need for transfusion not uncommon

Surgical Options

1.  Open antero-lateral approach 

Large / Massive Cuff Tear

2.  Deltopectoral approach

Large Subscapularis tear

3.  Arthroscopic Assisted Mini-open

Indication

- Small / Moderate Cuff Tear < 3cm

- no retraction

Technique

- arthroscopic SAD

Issues

Rotator cuff

- often deficient

Bone stock

- often deficient

Glenoid

- often posterior version 

Management

Options

1.  TSR

Indications

- cuff intact

Epidemiology

Male & Females > 60 years

- X-ray evidence of OA

Symptomatic 

- 25% females

- 15% males

Affected joints

Base thumb

PIPJ / Bouchard's nodes

DIPJ / Heberden's nodes

Issues

Limb alignment

Risk that late posterolateral corner reconstruction will fail in the setting of the varus knee

- varus knee alignment and varus thrust in stance phase

- consider osteotomy first in this setting

Results

Posterolateral Corner Reconstruction

Moulton et al. Am J Sports Med 2016

- systematic review of PCL reconstruction for chronic injuries

- 450 patients

NHx

Natural History of ACL deficient knee is variable

- functional instability 15% - 90%

- progression to OA is variable

Depends on level of patient demands / activity

1.  Late meniscal injury in ACL deficient knee

15-25%

2.  Function

Daniels Am J Sports Med 1994

- 292 ACL defecients knees