Bipin Theruvil FRCS (T&O),FRCS (Ed&Glasg),MS AIIMS
@centerofhip
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Technique over technology, Chief of Arthroplasty @medtrustkochi , Asso Editor Indian J of Orthop, Fellowship trained hip surgeon
Kerala, India
Joined February 2012
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Percutaneous quilting is a simple but very useful technique in large Morel-Lavalle lesions like these. Addresses the primary pathology.
Mark out the boundary of the lesion first using a suction tip. Then apply sutures using 1 ethilon or similar from periphery to centre. 1/2
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Total misrepresentation in my opinion. Most of us would not even touch this instrument!!
#orthotwitter
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The whole hip spine THA conundrum is confusing. I find this pelvic model, the easiest to teach trainees how the functional version of acetabulum changes. As you sit , more of acetabulum comes into view, effectively increasing the functional anteversion on sitting.
#orthotwitter
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Surgeon walks into the patient's room after surgery, feeling very proud of his handiwork.
Patient, looks very serious, says:
"Doc, one screw has totally missed the plate 😠"
#orthotwitter
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Nature is intelligent and has ways of dealing with adversities.. So long as orthopods don't fiddle too much!
35m. Had an open floating knee injury 10 years ago. Healed without any additional procedures. Not the most perfect x-ray but normal rom in the knee.
#orthotwitter
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It is a pleasure to see bone healing with Masquelet technique. Here there was a 7 cm defect. These pics are at 4 mo intervals.
Masquelet 🧵1/4
#orthotwitter
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Robotic surgeon versus the non robotic surgeon 😉
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"Humility is just one surgery away!"
Great words my chief used to remind himself to stay grounded after a series of extremely successful surgeries. Intraop periprosthetic fractures, esp around the socket, though rare, are very humbling indeed! 1/2
#orthotwitter
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Reverse shoulders seem to work reasonably well in the elderly, so why not a reverse hemi?
#orthotwitter
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11 year old , came off his motocross bike.
Closed fracture. Artery intact / no compartment.
How would you fix this
#orthotwitter
?
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Spinopelvic dynamics in THA is complex topic. To simplify this for teaching, I think of it as two ends of a continuum: fixed lordosis at one end and fixed kyphosis at the other.These 3 AnkSpond pts who had THA recently, represent the "known known" concepts on the topic. 1/5🧵
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Some procedures though minor are very satisfying indeed. Solitary loose body blocking extension.
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Easy surgery, but high satisfaction quotient !
Abscess around symphysis, drained thru a Pfannenstiel incision 🧵
28 f, normal delivery 3 wks ago. Following this she developed severe pain around pelvis with difficulty walking. Referred to our unit as she had diastasis on X rays.
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Throckmorton's sign positive.
One of the very useful pieces of wisdom I recently gained on Twitter😉. Surprised there are many indexed studies about the validity of this sign!
#orthotwitter
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Zimmer is withdrawing CPT stems in view of higher risk(1.4%) of Periprosthetic fractures. CPT stems forged from cobalt chrome have double the risk of PPF as compared to stanless steel stems like Exeter.
#orthotwitter
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20/m high speed road traffic accident. Closed injury. Vessels normal.
#orthotwitter
,
Which order would you fix? Position? Implants?
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Is the radius broken? Had to recheck that the X rays were of the same limb.
Importance of two views.
#orthotwitter
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Very wide canal , I will be quick with reaming , sister..
and two hours later 😰
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Hey
#orthotwitter
, who is exploring this artery? Comes in at 8pm.
This 4 yr old is referred with a pink pulseless extremity. No compartment symptoms, intact nerves.
With the modest displacement on X rays , was surprised to see the angio findings.
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Patient with knee OA, advised TKR. Goes to a centre specialising in “regenerating cartilage” using PRP. Gets another X-ray there which is pretty normal as per the doctor !! Patient is told 3 injections of PRP will cure his pain.
Non weight bearing X-ray has its uses too!!
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"Simplicity is the ultimate sophistication"
Attended OPD, 3 months after surgery elsewhere.
Looks like Malleolar screws and a 3.5 DCP .
Going strong ..so far.
#orthotwitter
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Did tibial nail first. Went suprapatellar to avoid flexion. Did safe surgical dislocation and fixed the small head frag with headless screws. Acetabular wall frag was very thin. Used a 2.7 lag with a spring plate followed by a 6 hole recon to fix the transverse fx
#orthotwitter
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Consent ☑️
This is an athlete, who runs ultramarathons regularly. Even he doesn’t realise initially that he has broken his femur in this “fun” game.
Healed well with open redn. Biopsy and meta profile normal.
Sufficient torque can break even the strongest bone.
#orthotwitter
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Marginal impaction is common with PW fractures. Seen best on axial CT. The video shows elevation of an impacted fragment using fem head as template. Look at the damage to the femoral head. No wonder PW fracture dislocations have a bad reputation.
#orthotwitter
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Great article on surgical approaches to periprosthetic fractures.
Open access.
Extremely useful to anyone who fixes these fractures.
Hope
@BoneJointJ
publishes more such articles.
via
@BoneJointJ
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Hey
#orthotwitter
, what would you do with this # neck of femur?
60 m with a segmental femoral fracture, initially reated with a distal femoral nail. My vigilant junior notices an undisplaced, vertically oriented fracture on one view. This was not seen on initial X rays. 1/2
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One can use coverage of head by shell to guesstimate the cup inclination intraop.
My default stem, Corail, has a neck shaft angle of 135. In neutral position of leg, if plane of head is parallel to shell, the inclination is around 45. This is basic trigonometry.
#orthotwitter
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When using delta type frames for distal tibial fractures, this modification around the heel ensures consistent foot elevation prior to surgery.
#orthotwitter
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#orthotwitter
, identify this hip replacement. This 50 yr old developed a fracture after 20 years of surgery. Has anyone got any experience of revising these?
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Was worried to remove this implant after the reports on cold welding. Fortunately came out easy.
Massive bone loss in a thin neck.
Is the more “modern” FNS is a major improvement on the simpler DHS?
#orthotwitter
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This 15 yr old boy has a transphyseal # dislocation. On opening the hip, we found the head had buttonholed and was lying loose under the bursa.
Would you try and fix given he is a teen?
Or
Would you do a THA as it is predictable?
#orthotwitter
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The suction tip can be used to ensure the suture engages the deep fascia.
Found Tornetta's technique useful in small lesions, but have seen recurrence in the larger lesions we encounter in our country .
Description from my team👇
2/2
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Do you do scopic carpal tunnel release? This one had a two incision scope assisted release.Symptoms did not resolve. Found a lacerated median nerve. During training , long ago, there was a brief period when scopic release was popular.
#handsurgery
, Any specific indications now?
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Did this 12 years ago. 22F from Africa. Was a # dislocation which was neglected for 4 yrs.She contacted me recently on FB to tell that she is well and sent the X ray. Has had two babies, both normal deliveries,after THR.
Small pleasures of being an Orthopod!
#orthotwitter
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Good article from JPOSNA on improving communication while using C arm.
Open access link 👇
#orthotwitter
#medtwitter
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Blue ceramic heads from Kyocera.
Possibly to meet the rising demands from male patients who hate a pink femoral head😉
#Orthotwitter
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Fatigue failure of a cemented Thompson's prosthesis done 23 years ago.
Can see multiple cracks if you look carefully-apart from the obvious one at the neck.
This is failure caused by by repetitive applications of loads below the ultimate tensile strength
#orthotwitter
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Any one using peroneus longus as a graft in ACL?
Study from our trainee
@deepupunnoose
comparing SemiT and PL. Better graft size and no morbidity at a year in ankle function in the PL group. Long term results pending.
#orthotwitter
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When trying to place a cup in the true acetabulum in a dysplastic hip, start with exposing the socket to see the TAL. Place a Hohmann retractor infr to TAL. If in doubt confirm with C arm. Start reaming with the reamer hugging the inferior Hohmann.
#orthotwitter
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40 m, ORIF for distal radius #. 4 weeks post op presents with a deformity. Denies any trauma. The screw shafts had broken at junction with the head. Synthes LDRS plate was used. Is this a failure of surgical technique or technology
#orthotwitter
,
@InvictaOrtho
@DrBhavinJadav
?
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60 yr old, right groin pain. traumatic diastasis treated conservatively 20 yrs ago. To make matters worse he has a nonunion of a low transverse Fx too.
#orthotwitter
, how would you proceed?
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In our culture patients are very keen on removing metal. In fact one of the first questions they ask after ORIF is when can I get this removed! This 73 yr old had a refracture after removing the plate elsewhere.
Metal work removals have a high degree of morbidity
#orthotwitter
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65 yr old with Garden 4, fracture healed but with varus collapse. She was painful and walked with an abductor lurch. Happy after a THR.
#Orthotwitter
, How would you have treated this fracture?
Interesting read👇
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Referred as implant failure.
When AFF is treated with a DHS I count it as a 'surgeon failure'. Poor placement of screw has lead to the cut out. The fx has not healed.
AFF or not, subtroch fx are best treated with a nail.
Apologies for my weekend rant.
#orthotwitter
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This was a patient in whom I did a "minor" procedure in the acetabulum (for post dislocations)15 years ago. Can anyone identify the device? Purely historical and absolutely useless piece of information as no one uses it anymore!!!
#orthotwitter
Was popular in UK then.
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One way to check if a screw in intraarticular during acetabular open redn is to place the screw driver handle in the screw head. Then rotate the C arm coplanar to the screw driver. Remove the screw driver and get an end on view of the screw.
#orthotwitter
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It is important to examine postr impingement in full ext and max ER. These 3 patients had early dislocations. All have increased cup version. The surgeons reported they were stable at surgery. But on EUA following dislocation they were all unstable in full Ext/ ER. 1/2🧵
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THR after varus derot osteotomy in Perthes. CT the whole femur for version, which is about 50° here. If you do a "std" stem, the leg will end up in severe internal rotation. Here a modular SROM is useful.
These short videos show the key steps.
#orthotwitter
1/6 🧵
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“female surgeons have more favorable outcomes”
Looks like male surgeons will be out of work soon.. if patients read this latest JAMA article👇
#orthotwitter
, is there a difference in outcome based on gender?
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Referred as “PFNA failure”.
The minimum requirement for a PFNA to work, is that the screw should be in the head. This screw dug out a big hole in the antr column after coming out through the neck. Fortunately postr column was intact.
#orthotwitter
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Osteotomy in stiff hips:
Do abducted side first. Expose neck well and place Hohmanns superiorly and inf. Use C arm if in doubt. Single osteotomy will do usually, though here it is a db osteotomy (thru post approach here). Stack osteotomes to open the osteotomy
#orthotwitter
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55 m, comminuted fracture neck, comminuted PW, dislocation. ORIF of acetabulum and THR with 36 cer head, a yr post op. I know many would fix this. My experience with fixing this has not been great and all ended with THA
#orthotwitter
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Hey
#orthotwitter
, what would be your preferredtreatment in this 92 yr f, mobile independently indoors, prior to a minor fall at home. The fracture involves the tip of GT and the LT.
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#orthotwitter
, what would you have done differently? Reduction? Choice of implant? What is the likelyu prognosis?
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Hey,
#orthotwitter
, how would you manage the DRUJ in this patient?
Fix the ulnar styloid?
Radio ulnar wire?
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Hey
#paedsorth
guys, what’s the current recommendation of treatment for this 7 yr old boy with neglected ddh?
Is surgery recommended or too high a risk at this age ?
No other health issues. He has shortening/ limping but no pain.
#orthotwitter
.
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Do you give explanted implants back to the patients?👇 from the Facebook account of one of my patients after implant removal with permission! Shows his true feelings !
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Interesting one! 11m, football tackle, tender distal tibia.Initial X rays did not show a #, but we suspected a Type 1 SH tibia. Was in a cast for 6 weeks. He returned with severe pain/ limping at 3 months. Repeat Xrays/ CT/MR done. What's the likely diag?
#orthotwitter
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This one is an easy diagnosis!
14/m , painful elbow, FFD of 40 deg to 120 flexion , diagnosis/ treatment?
#orthotwitter
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Where I work, when this pic comes up in the morning meeting, the first question..I predict..would be "who did the hip"?
Doesn't happen for readmissions of TKR/trauma.
Hip dislocations feel very "personal' unlike any other complication
#orthotwitter
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Weber C #, in an active 24 yr old male. Preop, intraop and 2 weeks post surgery X rays attached . Is the reduction acceptable? Now two weeks down, If revising, what should be done?
#orthotwitter
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32f, underwent renal transplant for CRF and on polypharmacy. Had THRs for AVN about 6 years ago. Was investigated for thigh pain and was diagnosed as "stem tip pain" . Comes with a fracture on right. Cause? Was this preventable? What next? revise/ orif?
#orthotwitter
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33f, DFO in childhood. Presents with painful varus. Lat closing wedge osteotomy of femur alone would result in an oblique joint line as shown on planning. Did DFCWO and OWHTO.
Used Surgimap software. Free and useful in countries like ours with limited resources.
#orthotwitter
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I don't think orthopods should ever look at brain scans.
All I see is some character from Lord of the Rings
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Any "cunning” ideas to remove this? I have found K nails very difficult to get out as there are no proper extractors and bone grows into the grooves. Even if you cut in the middle extracting the ends are sometimes difficult. Whats your experience
#orthotwitter
?
62 year female operated for femur fracture 38 year ago on 1985 with k nail , now after self fall bending of nail and bone. Best option to treat this ??
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Hey
#orthotwitter
what do you think about the fixation? (Disclosure: Not mine)
What should be done next? How do you assess syndesmosis and fibular reduction?
@FootAndAnkleMD
@InvictaOrtho
@bonesmith_
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#orthotwitter
, this 60 yr old has developed severe low back and groin pain over the past month and finds it difficult to walk. No significant history other than epilepsy on long term phenobarbital. Diagnosis ? Cause ?
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Diagnosis
#orthotwitter
, 67 year old lady, THR 2003. Recently developed pain and noticed crepitus in the hip. Infection screen negative. How would you plan her revision?
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ETO heals predictably, even in multiply operated cases like this, when the soft tissues are handled with care. Keep the glut medius/ vastus sling intact to avoid a flying trochanter.
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Who is nailing this in lateral position vs supine ?
70 f, no trauma /pre-existing medical problems, leg just gave way. Very small lateral beak, suspicious of a bisphosphonate induced Fx, though no history.
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22m with # femur and pubic diastasis. Was planned for symphysis fixation, but could not reduce closed . Turned out to be a congenital diastasis
If symphysis is not reducible on bitrochanteric compression under anesthesia, check if this is a cong diastasis.
#orthotwitter
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Challenging one, 75m, Periprosthetic fx fixed outside the country a year ago. No infection. Implant appears stable. Atleast 2 broken screws.
#orthotwitter
, why did this fail?
What next? Bone graft? DFR? Refix with plat or nail plate?
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Somone today forwarded this x-ray and asked me which implant to use as their first question😩.
What will be your response?
..... mine was this 😉👇
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36f, RTA, right foot drop. Hey
#orthotwitter
in what sequence would you fix with in this complex injury? What construct would you choose?
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55 yr old bus conductor. Non smoker. Metabolic work up normal.
Closed injury in a road accident during Covid time. Surgery was deferred initially and subsequently never got operated. Skin condition good.
#orthotwitter
what’s your preferred method of treatment here?
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3D modelling is quite useful in complex cases. This young guy presented with HO and an intrarticular fusion after an acetabular Orif. CT showed protrusio also.
#orthotwitter
1/3
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Wish more surgeons use the 2 holed DHS for fixing intracapsular neck femur fractures. Revisions are made easy. Rare to see a failure at the shaft fixation.
#orthotwitter
, is a 2 holed DHS enough for intertroch# as well?
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Displaced supracondylar in 1 year old, closed pinning done elsewhere. Presents two weeks later with this X-ray. Immed post op x rays are also in the same position. Revise now? Would you leave alone and do an osteotomy later?
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80f with treated PFNA elsewhere. TAD corrected for magnification is 24mm. No wound healing issues,crp/esr normal. Why did this fail?
Short nail? Short screw impinging lat cortex? Due to Displaced GT?
#orthotwitter
@InvictaOrtho
@Orthodoc2031
@stevemchale
@bonesmith_
@pratikorho
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If you rely on TAL during THA, one may find that TAL cant be seen, once the shell is half in. Use a Hohmann retractor perpendicular to TAL to use it as an external guide. Line up the shell inserter with this retractor to get a cup position parallel to TAL
#orthotwitter
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Orthogonal views are important
#orthotwitter
#MedTwitter
This weight bearing lateral X ray changed the choice of my TKR implant
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Amazed that surgeons still do DHS in subtroch fractures. This one failed in 6 months.
Initially put him on fracture table and the apex lateral deformity became worse. So turned to him to lateral position. Healed in 4 months.
#orthotwitter
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Why do you think knee pain is so common in SUFE unlike other paeds conditions like Perthes? 13f with knee pain was seen by GP, Ortho and paeds rheum . Opined after multiple inv including an MR brain that it was functional😮. An astute neurologist picks up the Dx
#orthotwitter
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Diagnosis and treatment for the third toe deformity in this 3 month old baby ,
#orthotwitter
?
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Does anyone measure thickness of the cut trochlea during a TKR?
At APAS, Prof David Barrett today spoke about the "third space" in TKR. Discussed how overstuffing or understuffing the trochlea can change the patfem dynamics to cause antr knee pain 1/2
Here is the article 👇
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If pain is out of proportion to findings, worth investigating further before an arthroplasty.
75m, right THR for unremitting night pain. Pain continues after THR, infection screen neg. The tumour became more visible after a few months. Final diagnosis : Lung met
#orthotwitter
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Surgeon forgot to put the ball tipped wire while reaming. Nurse noticed the reamer missing. Blocked with a k wire to stop it going down. Fortunately came out with a reverse curette used in revision hips.
#orthotwitter
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72 f, AM done 10 years ago. Revised for pain elsewhere. A month later presents to us with shortening and not able to weigh bear with a post column#. No trauma.
Would appreciate your insights into the cause of the fracture and the treatment.
#orthotwitter
@BrianChalmersMD
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One article that will change my practice. 4 weeks of casting is enough in distal radius fractures.
🦴 FOUR WEEKS VERSUS SIX WEEKS OF IMMOBILIZATION IN A CAST FOLLOWING CLOSED REDUCTION FOR DISPLACED DISTAL RADIAL FRACTURES IN ADULT PATIENTS 🤝
Read the full paper now!
#Fracture
#WristFracture
#RCT
#Orthopedics
#VideoAbstract
#BJJ
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Tried reducing it supine on a fracture table. Got reasonable alignment. Used encirclage for the segmental part of the fracture. A clamp was used to derotate and adduct the prox fragment for getting a slightly medial entry. Biopsy also was done which was normal.
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Spot the problem, that required a revision. 78 m with no medical issues , Buechel Pappas TKR done 10 yrs ago. Sudden onset pain abt 45 days ago rom 5-60 . Infection markers normal and aspirate culture negative.
#orthotwitter
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Very tall boy. Felt dual plating would be more stable as the orientation of the fx along with the physis below precluded adequate bicortical purchase. Raised vasti laterally and then medially through separate incisions. Stayed extraphyseal. Postmed tib plate medially and distal
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Remember one of my trainers saying "no one looks good removing metalwork"! All the more true when attempting removal of locked screws. This article in Injury from my trainees show that removal of screws manually using a T handle is more successful than power.
#orthotwitter
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65 yr old farmer, no comorbidities , BMI 26, severe pain in his knee 6 weeks. Tried an offloading brace and physio without relief. How would you treat him?
@kneedoclond
@kneepreserve
@KneeUnit
#orthotwitter
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