This document summarizes an evening webinar presented by Sacramento Orthopedic Center and Results Physical Therapy on ultrasound guided injections. The webinar covered how ultrasound can improve injection accuracy and patient outcomes. It introduced affordable point-of-care ultrasound units and discussed appropriate use of corticosteroids versus orthobiologics like PRP and stem cells. The presenters were doctors and physical therapists who collaborate on treatment protocols using medical and physical therapy approaches.
A presentation on different techniques for shoulder joint preservation in regards to the advances in technology for rotator cuff pathology, from tendonitis to cuff tear arthropathy.
This document provides information about PASTA (Partial Articular Supraspinatus Tendon Avulsion) lesions and repair techniques. It discusses methods for determining the size of PASTA lesions, current recommendations for repair vs. debridement, and repair options. It then describes a new PASTA repair technique called the "PASTA Bridge", which does not require knot tying. Preliminary results of a clinical study comparing the PASTA Bridge technique to trans-tendon repair show no significant differences in pain or function scores between the groups, and a lower failure rate for the PASTA Bridge. The PASTA Bridge is proposed as an easy, percutaneous alternative to other PASTA repair methods.
This document provides an overview of ultrasound-guided injection procedures for the lower extremities performed by Dr. Alan Hirahara, including injections for the knee, hip, muscles, foot and ankle. It lists various conditions that can be treated with injections such as knee effusions, patellar tendonopathy, plantar fasciitis and Achilles tendon injuries. Images are also included showing ultrasound views and techniques for different injection approaches.
This document summarizes a study on AC joint separations and associated intra-articular shoulder pathology. The study reviewed 18 patients with AC separations requiring repair and found that 61% had some form of intra-articular pathology like SLAP tears, partial RCT tears, or full RCT tears. The conclusion is that AC separations have a high rate of concurrent intra-articular injuries, so MRI or arthroscopy before AC joint repair is recommended to identify any additional pathology.
- The document discusses incorporating new biologic technologies into an orthopedic practice, including biocartilage, platelet-rich plasma (PRP), and allograft technologies.
- The author has had success using biocartilage to treat chondral defects arthroscopically, finding it a low-cost and easy alternative to other treatments. Studies also support the use of PRP to reduce pain and inflammation in osteoarthritis.
- New allograft technologies like pre-sutured tendon constructs can reduce surgery time and provide consistent grafts for ACL reconstruction compared to autografts. Filling bone tunnels in ACL reconstruction with demineralized bone matrix carriers like StimuBlast may also
ACJ revision surgery for failed reconstructions and excisionsLennard Funk
This document discusses ACJ revision surgery. It provides information on the functional anatomy of the AC joint, causes of failed ACJ excision or reconstruction, and describes a technique for ACJ revision surgery. The technique involves removing scar tissue from previous procedures, taking micro samples, performing an anatomical reconstruction of the CC and AC ligaments using LARS ligaments and a biceps flip or CAL transfer, and performing a delto-trapezial reefing. Results from 23 revision cases over 7 years showed improved Constant scores, low rates of re-displacement and infection, and no need for further revision after a mean follow up of 37 months.
Rotator Cuff Update 2022 for Medbelle Len Funk.pptxLennard Funk
the common questions patients will ask once they have had a scan and a tear has been reported, particularly if they have had no injury of trauma, they ask what caused my tear. If I have a tear what can you do to fix it, it’s got to be fixed. How can I get better if it is not fixed. I have already had physiotherapy and that didn’t fix it so how will more physiotherapy. Some patients who are not keen on surgery, do I really need to have an operation. I have not had an injury.
there are multiple options thrown into the mix here which we need to consider for an individual patient.
The below illustration shows a very rough decision making tool that I would use in determining surgical or treatment options for particular patients.
A younger patient who has both pain and weakness with a massive cuff tear, if it is partially repairable a biological augment would be suitable.
If their predominant weakness is external rotation i.e. a positive Hornblower sign but good elevation, a lat dorsi tendon transfer.
For an older patient who has a predominant weakness but no significant pain, deltoid rehabilitation programme is indicated.
If they do have pain, a suprascapular nerve procedure such as an ablation would be beneficial.
For those that have significant pain and weakness with failed non-operative options, a reverse shoulder replacement would be the best option.
The balloon as we said, has a very limited place and this is for the older patient with slight loss of function and pain with higher demands.
For those that have more significant pain and elevation weakness, a superior capsular reconstruction would be my preferred option.
A presentation on different techniques for shoulder joint preservation in regards to the advances in technology for rotator cuff pathology, from tendonitis to cuff tear arthropathy.
This document provides information about PASTA (Partial Articular Supraspinatus Tendon Avulsion) lesions and repair techniques. It discusses methods for determining the size of PASTA lesions, current recommendations for repair vs. debridement, and repair options. It then describes a new PASTA repair technique called the "PASTA Bridge", which does not require knot tying. Preliminary results of a clinical study comparing the PASTA Bridge technique to trans-tendon repair show no significant differences in pain or function scores between the groups, and a lower failure rate for the PASTA Bridge. The PASTA Bridge is proposed as an easy, percutaneous alternative to other PASTA repair methods.
This document provides an overview of ultrasound-guided injection procedures for the lower extremities performed by Dr. Alan Hirahara, including injections for the knee, hip, muscles, foot and ankle. It lists various conditions that can be treated with injections such as knee effusions, patellar tendonopathy, plantar fasciitis and Achilles tendon injuries. Images are also included showing ultrasound views and techniques for different injection approaches.
This document summarizes a study on AC joint separations and associated intra-articular shoulder pathology. The study reviewed 18 patients with AC separations requiring repair and found that 61% had some form of intra-articular pathology like SLAP tears, partial RCT tears, or full RCT tears. The conclusion is that AC separations have a high rate of concurrent intra-articular injuries, so MRI or arthroscopy before AC joint repair is recommended to identify any additional pathology.
- The document discusses incorporating new biologic technologies into an orthopedic practice, including biocartilage, platelet-rich plasma (PRP), and allograft technologies.
- The author has had success using biocartilage to treat chondral defects arthroscopically, finding it a low-cost and easy alternative to other treatments. Studies also support the use of PRP to reduce pain and inflammation in osteoarthritis.
- New allograft technologies like pre-sutured tendon constructs can reduce surgery time and provide consistent grafts for ACL reconstruction compared to autografts. Filling bone tunnels in ACL reconstruction with demineralized bone matrix carriers like StimuBlast may also
ACJ revision surgery for failed reconstructions and excisionsLennard Funk
This document discusses ACJ revision surgery. It provides information on the functional anatomy of the AC joint, causes of failed ACJ excision or reconstruction, and describes a technique for ACJ revision surgery. The technique involves removing scar tissue from previous procedures, taking micro samples, performing an anatomical reconstruction of the CC and AC ligaments using LARS ligaments and a biceps flip or CAL transfer, and performing a delto-trapezial reefing. Results from 23 revision cases over 7 years showed improved Constant scores, low rates of re-displacement and infection, and no need for further revision after a mean follow up of 37 months.
Rotator Cuff Update 2022 for Medbelle Len Funk.pptxLennard Funk
the common questions patients will ask once they have had a scan and a tear has been reported, particularly if they have had no injury of trauma, they ask what caused my tear. If I have a tear what can you do to fix it, it’s got to be fixed. How can I get better if it is not fixed. I have already had physiotherapy and that didn’t fix it so how will more physiotherapy. Some patients who are not keen on surgery, do I really need to have an operation. I have not had an injury.
there are multiple options thrown into the mix here which we need to consider for an individual patient.
The below illustration shows a very rough decision making tool that I would use in determining surgical or treatment options for particular patients.
A younger patient who has both pain and weakness with a massive cuff tear, if it is partially repairable a biological augment would be suitable.
If their predominant weakness is external rotation i.e. a positive Hornblower sign but good elevation, a lat dorsi tendon transfer.
For an older patient who has a predominant weakness but no significant pain, deltoid rehabilitation programme is indicated.
If they do have pain, a suprascapular nerve procedure such as an ablation would be beneficial.
For those that have significant pain and weakness with failed non-operative options, a reverse shoulder replacement would be the best option.
The balloon as we said, has a very limited place and this is for the older patient with slight loss of function and pain with higher demands.
For those that have more significant pain and elevation weakness, a superior capsular reconstruction would be my preferred option.
Patient Specific Instrumentation in Total Knee ReplacementVaibhav Bagaria
Use of patient Specific Instruments in Knee replacement has generated tremendous interests, won accolades and also have been showered brick bats. A presentation about its true relevance in modern Knee replacement surgery.
Assessment of Femoral Tunnel Placement in ACL ReconstructionJeremy Burnham
This study reviews the literature on tunnel placement in anterior cruciate ligament reconstruction, and assess the ability of experienced physicians and surgeons to evaluate the tunnel position using x-rays.
Pectoralis Major Injuries for BESS 2020Lennard Funk
This document discusses pectoralis major injuries, including anatomy, diagnosis, treatment options, and outcomes. It provides an overview of the author's experience treating tears in athletes from various sports. Diagnosis involves clinical exam and imaging like ultrasound or MRI. Treatment can be non-operative with strength loss, or operative with surgical repair which often provides best results, especially for distal tears. Post-operative rehabilitation is outlined in phases focusing first on range of motion and later on strengthening. Reported outcomes include patients regaining 90% of strength on average and returning to sports within 6 months.
Lennard Funk presented on the clinical and radiological assessment of shoulder instability in athletes. He discussed evaluating anterior and posterior instability through physical examination tests in different positions and assessing glenoid and humeral bone loss on imaging studies like MRI arthrograms. Funk also covered management strategies and decision making, which involves considering factors related to the patient, their profession, the type and extent of pathology, and the treating physician.
Revisions of failed Latarjet surgery 2015Lennard Funk
This study reviewed outcomes of revision procedures for failed Latarjet surgery in 16 patients over 5 years. The most common direction of recurrent instability was anterior (11 cases). Common causes of failure included coracoid non-union (7 cases) and capsular laxity (8 cases). Revision procedures included Eden-Hybinette (5 cases), arthroscopic stabilization (8 cases), and remplissage (1 case). Complications occurred in 4 revisions. Most patients (12/16) and professionals (9/11) returned to their pre-injury level of sport following revision. Capsular laxity and posterior lesions were implicated in recurrent multi-directional and posterior instability cases.
This document provides information about a new arthroscopic biceps tenodesis technique. It summarizes a study comparing 14 patients who underwent the new technique to 9 patients who had a biceps tenotomy. The new technique resulted in significantly less pain and higher function scores at various points as measured by questionnaires, though it carries a small risk of needing to be converted to a tenotomy if the fixation pulls out. The technique was found to be easy to perform and yielded better outcomes than tenotomy while avoiding complications of proximal fixation methods.
Management of Primary Traumatic Shoulder Instabilitywashingtonortho
This document discusses the management of primary traumatic shoulder instability through a presentation by Dr. J.R. Rudzki. Some key points discussed include:
- Age is a primary risk factor for recurrence, with rates of 100% in patients <10 years old and 79% in patients aged 20-30 years old.
- Surgical stabilization may have better outcomes than conservative treatment for young, active patients based on data from randomized controlled trials.
- For first-time dislocators, arthroscopic Bankart repair reduces the risk of recurrent instability by 76-82% compared to non-operative management.
- Factors like glenoid bone loss, large Hill-Sachs lesions, and capsular
Elbow instability Jill Thomas NWULG may 2018Lennard Funk
Jill Thomas from the Upper Limb Unit at Wrightington Hospital presents on rehabilitation for elbow instability - presented to the North West Upper Limb Group (www.nwulg.org)
Rotator cuff Repair in Rugby 2015 funkLennard Funk
1) Arthroscopic rotator cuff repair was performed on 11 elite rugby players with significant rotator cuff injuries.
2) The tears ranged in size from small (<1cm) to massive (>5cm), with a mean size of 1.8cm. Post-operative ultrasound scans showed the repairs to be intact in all 9 cases that were checked.
3) All players but one returned to play at the same level, with the mean time to return to full match play being 4.8 months. The study concludes that rotator cuff tears are not uncommon in rugby players and arthroscopic repair can enable players to return to play.
Suture anchor Bone Response Validation StudyLennard Funk
1. This study validated a novel 5-point grading system to assess bone response around suture anchors following shoulder labral reconstruction using MRI scans.
2. The validation study found moderate to substantial interrater and intrarater reliability among musculoskeletal radiologists and shoulder surgeons when using the grading system.
3. The results suggest the grading system is feasible for clinical use and the next steps are to provide rater training and validate the system in other medical centers to further improve reliability.
Custom Fit or Patient Specific Knee Replacement Surgery in Gurgaon by Dr Jaya...Gurgaonkneeshoulderclinic
We offer most advanced technique of Knee replacement surgery-- Custom Fit implants. Dr Jayant Arora is a renowned Knee replacement surgeon in Gurgaon with years of experience in England and Scotland. He is the Chief of Orthopedic Surgery at Columbia Asia Hospital in Gurgaon since 2008. He is a pioneer of this technique in Gurgaon. Hundreds of patients have benefited from this latest technique leading to a painless quick recovery after the surgery. There are many advantages of this technique as compared to traditional way of doing the surgery, namely shorter surgery time, less blood loss, smaller incision and better precision in the fitting of the implants. This leads to your artificial knee feeling as natural knee!!
Feel free to email us at gurgaonkneeshoulderclinic@gmail.com if you have any queries about knee replacement surgery
The document compares the posterior approach (PA) and direct anterior approach (DAA) for total hip arthroplasty (THA). It finds that the DAA results in less muscle damage, less pain/narcotic use, earlier discharge from the hospital, and faster recovery of hip function and gait speed based on multiple studies. However, both approaches have similar risks of dislocation and comparable functional outcomes at one year post-operation. Patient factors like BMI, age, and compliance with hip precautions also impact outcomes.
There is no “gold standard” technique for the surgical stabilization of Acromioclavicular joint (ACJ) disruptions and each of the described techniques has a failure rate. The management of failed ACJ stabilizations is a difficult problem and salvage procedures may often be constrained by the original procedure and the resultant anatomy. Reliable anatomical and biomechanically robust revision procedures for failed ACJ stabilization are therefore required. We describe a technique for revision stabilization of the ACJ that utilises a synthetic ligament in combination with augmentation from the coracoacromial ligament and biceps short head aponeurosis (‘biceps flip’ procedure).
This document summarizes research on hip dislocation rates following total hip arthroplasty depending on surgical approach. It finds that the risk of dislocation is greatest in the first 3 months post-operation, and varies based on surgical approach and risk factors like age and joint condition. Specifically, it reports that posterior approaches have the lowest dislocation rates when soft tissue repair is performed, ranging from 0.49-1.01%, while rates are higher without repair. Anterior-lateral approaches have dislocation rates of 0.7%. The document concludes that more studies are needed but there may be no increased dislocation risk for anterior approaches without precautions.
This document discusses knee arthritis and surgical treatment options. It begins with introductions of two orthopaedic surgeons, Jarrad Stevens and Dave Slattery. It then discusses where orthopaedic surgeons fit in the treatment of knee arthritis, noting they are involved when non-surgical options are exhausted and the patient will benefit from joint replacement. Surgical approaches for knee replacement are described, including use of a medial parapatellar incision. Robotic replacement is discussed as providing accurate placement of components. Options for partial versus total knee replacement are presented, and the future of knee replacement surgery is addressed.
total knee replacement in tobruk medical center in, libyasana I . Souliman
The aim of this study to investigate about the causes that lead to total knee joint replacement operation, especially the operation that is performed in Medical Tobruk Center where there are many reasons that cause problem in Knee joint but in tobruk . And the knee joint ,which is one of the largest and most complex joints in the human body.
This document summarizes information about extracellular matrix (ECM) patches for rotator cuff repair augmentation. It notes that reported failure rates for rotator cuff repairs are between 20-57% and that animal and biomechanical studies support the use of acellular dermal grafts for augmentation. However, several grafts still contain significant DNA. While dermal grafts show potential for augmentation in some clinical studies, other studies using acellular dermal grafts like SIS were discontinued early due to lack of benefit or inflammatory reactions. Intercalary graft placement in biomechanical studies shows equivalent properties to native tissue but few clinical studies demonstrate long term success.
This document discusses the importance of detecting and properly reporting vertebral fractures seen on imaging studies. It notes that vertebral fractures are common but often go unreported, and early detection can help prevent future fractures and morbidity. The document describes audits conducted at Bradford Royal Infirmary that found low rates of vertebral fracture reporting and recommendations for osteoporosis screening. Actions taken include providing spine reconstructions for CTs, educating radiologists, and allowing direct referrals for bone density tests. A follow-up audit showed improvements in detection and reporting but also continued room for progress.
1. This document describes a study protocol to evaluate if pre-procedural ultrasound of the lumbar spine can improve the procedural skill of performing subarachnoid blocks.
2. The study aims to compare outcomes like success on the first needle pass, number of needle passes, time taken between groups who receive pre-procedure ultrasound versus those who do not.
3. A review of previous literature found that ultrasound can help identify anatomy like the posterior longitudinal ligament that indicates ease of dural puncture, and may help predict difficult procedures. Simulation training and deliberate practice was also found to improve residents' skills in performing subarachnoid blocks.
Patient Specific Instrumentation in Total Knee ReplacementVaibhav Bagaria
Use of patient Specific Instruments in Knee replacement has generated tremendous interests, won accolades and also have been showered brick bats. A presentation about its true relevance in modern Knee replacement surgery.
Assessment of Femoral Tunnel Placement in ACL ReconstructionJeremy Burnham
This study reviews the literature on tunnel placement in anterior cruciate ligament reconstruction, and assess the ability of experienced physicians and surgeons to evaluate the tunnel position using x-rays.
Pectoralis Major Injuries for BESS 2020Lennard Funk
This document discusses pectoralis major injuries, including anatomy, diagnosis, treatment options, and outcomes. It provides an overview of the author's experience treating tears in athletes from various sports. Diagnosis involves clinical exam and imaging like ultrasound or MRI. Treatment can be non-operative with strength loss, or operative with surgical repair which often provides best results, especially for distal tears. Post-operative rehabilitation is outlined in phases focusing first on range of motion and later on strengthening. Reported outcomes include patients regaining 90% of strength on average and returning to sports within 6 months.
Lennard Funk presented on the clinical and radiological assessment of shoulder instability in athletes. He discussed evaluating anterior and posterior instability through physical examination tests in different positions and assessing glenoid and humeral bone loss on imaging studies like MRI arthrograms. Funk also covered management strategies and decision making, which involves considering factors related to the patient, their profession, the type and extent of pathology, and the treating physician.
Revisions of failed Latarjet surgery 2015Lennard Funk
This study reviewed outcomes of revision procedures for failed Latarjet surgery in 16 patients over 5 years. The most common direction of recurrent instability was anterior (11 cases). Common causes of failure included coracoid non-union (7 cases) and capsular laxity (8 cases). Revision procedures included Eden-Hybinette (5 cases), arthroscopic stabilization (8 cases), and remplissage (1 case). Complications occurred in 4 revisions. Most patients (12/16) and professionals (9/11) returned to their pre-injury level of sport following revision. Capsular laxity and posterior lesions were implicated in recurrent multi-directional and posterior instability cases.
This document provides information about a new arthroscopic biceps tenodesis technique. It summarizes a study comparing 14 patients who underwent the new technique to 9 patients who had a biceps tenotomy. The new technique resulted in significantly less pain and higher function scores at various points as measured by questionnaires, though it carries a small risk of needing to be converted to a tenotomy if the fixation pulls out. The technique was found to be easy to perform and yielded better outcomes than tenotomy while avoiding complications of proximal fixation methods.
Management of Primary Traumatic Shoulder Instabilitywashingtonortho
This document discusses the management of primary traumatic shoulder instability through a presentation by Dr. J.R. Rudzki. Some key points discussed include:
- Age is a primary risk factor for recurrence, with rates of 100% in patients <10 years old and 79% in patients aged 20-30 years old.
- Surgical stabilization may have better outcomes than conservative treatment for young, active patients based on data from randomized controlled trials.
- For first-time dislocators, arthroscopic Bankart repair reduces the risk of recurrent instability by 76-82% compared to non-operative management.
- Factors like glenoid bone loss, large Hill-Sachs lesions, and capsular
Elbow instability Jill Thomas NWULG may 2018Lennard Funk
Jill Thomas from the Upper Limb Unit at Wrightington Hospital presents on rehabilitation for elbow instability - presented to the North West Upper Limb Group (www.nwulg.org)
Rotator cuff Repair in Rugby 2015 funkLennard Funk
1) Arthroscopic rotator cuff repair was performed on 11 elite rugby players with significant rotator cuff injuries.
2) The tears ranged in size from small (<1cm) to massive (>5cm), with a mean size of 1.8cm. Post-operative ultrasound scans showed the repairs to be intact in all 9 cases that were checked.
3) All players but one returned to play at the same level, with the mean time to return to full match play being 4.8 months. The study concludes that rotator cuff tears are not uncommon in rugby players and arthroscopic repair can enable players to return to play.
Suture anchor Bone Response Validation StudyLennard Funk
1. This study validated a novel 5-point grading system to assess bone response around suture anchors following shoulder labral reconstruction using MRI scans.
2. The validation study found moderate to substantial interrater and intrarater reliability among musculoskeletal radiologists and shoulder surgeons when using the grading system.
3. The results suggest the grading system is feasible for clinical use and the next steps are to provide rater training and validate the system in other medical centers to further improve reliability.
Custom Fit or Patient Specific Knee Replacement Surgery in Gurgaon by Dr Jaya...Gurgaonkneeshoulderclinic
We offer most advanced technique of Knee replacement surgery-- Custom Fit implants. Dr Jayant Arora is a renowned Knee replacement surgeon in Gurgaon with years of experience in England and Scotland. He is the Chief of Orthopedic Surgery at Columbia Asia Hospital in Gurgaon since 2008. He is a pioneer of this technique in Gurgaon. Hundreds of patients have benefited from this latest technique leading to a painless quick recovery after the surgery. There are many advantages of this technique as compared to traditional way of doing the surgery, namely shorter surgery time, less blood loss, smaller incision and better precision in the fitting of the implants. This leads to your artificial knee feeling as natural knee!!
Feel free to email us at gurgaonkneeshoulderclinic@gmail.com if you have any queries about knee replacement surgery
The document compares the posterior approach (PA) and direct anterior approach (DAA) for total hip arthroplasty (THA). It finds that the DAA results in less muscle damage, less pain/narcotic use, earlier discharge from the hospital, and faster recovery of hip function and gait speed based on multiple studies. However, both approaches have similar risks of dislocation and comparable functional outcomes at one year post-operation. Patient factors like BMI, age, and compliance with hip precautions also impact outcomes.
There is no “gold standard” technique for the surgical stabilization of Acromioclavicular joint (ACJ) disruptions and each of the described techniques has a failure rate. The management of failed ACJ stabilizations is a difficult problem and salvage procedures may often be constrained by the original procedure and the resultant anatomy. Reliable anatomical and biomechanically robust revision procedures for failed ACJ stabilization are therefore required. We describe a technique for revision stabilization of the ACJ that utilises a synthetic ligament in combination with augmentation from the coracoacromial ligament and biceps short head aponeurosis (‘biceps flip’ procedure).
This document summarizes research on hip dislocation rates following total hip arthroplasty depending on surgical approach. It finds that the risk of dislocation is greatest in the first 3 months post-operation, and varies based on surgical approach and risk factors like age and joint condition. Specifically, it reports that posterior approaches have the lowest dislocation rates when soft tissue repair is performed, ranging from 0.49-1.01%, while rates are higher without repair. Anterior-lateral approaches have dislocation rates of 0.7%. The document concludes that more studies are needed but there may be no increased dislocation risk for anterior approaches without precautions.
This document discusses knee arthritis and surgical treatment options. It begins with introductions of two orthopaedic surgeons, Jarrad Stevens and Dave Slattery. It then discusses where orthopaedic surgeons fit in the treatment of knee arthritis, noting they are involved when non-surgical options are exhausted and the patient will benefit from joint replacement. Surgical approaches for knee replacement are described, including use of a medial parapatellar incision. Robotic replacement is discussed as providing accurate placement of components. Options for partial versus total knee replacement are presented, and the future of knee replacement surgery is addressed.
total knee replacement in tobruk medical center in, libyasana I . Souliman
The aim of this study to investigate about the causes that lead to total knee joint replacement operation, especially the operation that is performed in Medical Tobruk Center where there are many reasons that cause problem in Knee joint but in tobruk . And the knee joint ,which is one of the largest and most complex joints in the human body.
This document summarizes information about extracellular matrix (ECM) patches for rotator cuff repair augmentation. It notes that reported failure rates for rotator cuff repairs are between 20-57% and that animal and biomechanical studies support the use of acellular dermal grafts for augmentation. However, several grafts still contain significant DNA. While dermal grafts show potential for augmentation in some clinical studies, other studies using acellular dermal grafts like SIS were discontinued early due to lack of benefit or inflammatory reactions. Intercalary graft placement in biomechanical studies shows equivalent properties to native tissue but few clinical studies demonstrate long term success.
This document discusses the importance of detecting and properly reporting vertebral fractures seen on imaging studies. It notes that vertebral fractures are common but often go unreported, and early detection can help prevent future fractures and morbidity. The document describes audits conducted at Bradford Royal Infirmary that found low rates of vertebral fracture reporting and recommendations for osteoporosis screening. Actions taken include providing spine reconstructions for CTs, educating radiologists, and allowing direct referrals for bone density tests. A follow-up audit showed improvements in detection and reporting but also continued room for progress.
1. This document describes a study protocol to evaluate if pre-procedural ultrasound of the lumbar spine can improve the procedural skill of performing subarachnoid blocks.
2. The study aims to compare outcomes like success on the first needle pass, number of needle passes, time taken between groups who receive pre-procedure ultrasound versus those who do not.
3. A review of previous literature found that ultrasound can help identify anatomy like the posterior longitudinal ligament that indicates ease of dural puncture, and may help predict difficult procedures. Simulation training and deliberate practice was also found to improve residents' skills in performing subarachnoid blocks.
Patient Specific Instrumentation in TKRBushu Harna
CT guided jig assisted TKA was compared to conventional instrumentation TKA. The study found that CT guided jigs resulted in more accurate restoration of knee alignment angles and placement of components. Specifically, the HKA and FS-TS angles were closer to ideal values with less deviation when using CT guided jigs. Additionally, CT guided jigs led to less blood loss as indicated by lower drain outputs. However, the study noted that the benefits were small and not alone justification for routine use of CT guided jigs. Larger studies are still needed to validate the results.
This document summarizes a clinical scenario involving a 14-year-old male presenting with left knee pain and swelling after injury during soccer practice. Based on physical exam findings of effusion, limited range of motion, and joint line tenderness, diagnostic imaging is warranted per the Ottawa Knee Rule. The document discusses ultrasound and MRI for diagnosing potential injuries like an ACL tear or meniscal tear, noting the efficacy, limitations, and appropriate use of each imaging modality to assist in diagnosis and potential referral for surgical repair.
Balancing Risks and Benefits of Regional AnaesthesiaColin McCartney
This document discusses the benefits and risks of regional anesthesia. It notes that regional anesthesia provides significant benefits for patients such as better pain control, reduced complications, and faster recovery. However, risks are also present though low. The document emphasizes taking a pragmatic approach that balances the benefits and risks for each individual patient. It also stresses the importance of clear explanation and documentation of informed consent. Proper training, use of standardized techniques, and a focus on patient safety are recommended to maximize benefits and minimize risks.
Twenty years of evar in the us the procedure that changed a specialtyuvcd
The document discusses the major impact that endovascular aneurysm repair (EVAR) has had on the field of vascular surgery over the past 20 years. It summarizes that EVAR blurred specialty relationships, forced retraining of vascular surgeons, changed operating room practices, doubled training requirements, promoted vascular surgery as a specialty, and increased demand for and compensation of vascular surgeons. Randomized clinical trials showed EVAR had superior early outcomes compared to open repair for abdominal aortic aneurysms. This led to its rapid adoption in the United States despite many patients having hostile anatomies for the procedure.
A study of core decompression & free fibular strut grafting in the management...Vltech Knr
Core decompression and free fibular strut grafting were studied as a treatment for osteonecrosis of the femoral head. In the study of 28 hips with Ficat-Arlet grade 1-3 osteonecrosis, 67.86% of patients experienced pain relief after the procedure. At the 6-month follow up, 82.61% of patients were considered surgical successes based on Harris Hip Scores and radiographic evidence. However, 8 hips showed further advancement of osteonecrosis despite the procedure. The study concluded that core decompression with fibular grafting can effectively treat early stage osteonecrosis, but patient factors like age, hip flexibility, and adherence to post-op care affected outcomes.
Analysis of Spinal Decompression via Surgical Methods and Traction TherapyPaige Barrett
This document summarizes various surgical and non-surgical methods for spinal decompression to treat back pain. For surgical decompression of the cervical spine, early surgery (<24 hrs) after spinal cord injury produces better outcomes than delayed surgery. Circumferential decompression and fusion is effective for cervical myelopathy. In the thoracic spine, posterior decompression with instrumented fusion improves neurological functioning for thoracic myelopathy. Video-assisted thoracoscopic surgery and percutaneous laser disc decompression are suitable minimally invasive options for the thoracic spine. For the lumbar spine, indirect decompression using an interbody cage is effective for degenerative lumbar stenosis, while decompression without fusion significantly decreases leg pain and disability. Minimally invasive
MSK Ultrasound and Guided Injections in Private PracticeAamir Safdar-Khan
Diagnostic Musculoskeletal Ultrasound and Ultrasound Guided Injections in Private Practice. Basics for Podiatrists and Advance Practice Physiotherapists who wanted to learn the diagnostic ultrasound, implement and improve musculoskeletal practice as POCUS (point of care ultrasound). Other healthcare professionals can also benefit such as sonographers, osteopath, chiropractors.
Short term outcomes of Intertrochanteric Imhauser Osteotomy combined with ost...Shady Mahmoud
The document summarizes a study assessing the short-term outcomes of using intertrochanteric osteotomy combined with osteochondroplasty to treat moderate to severe stable slipped capital femoral epiphysis (SCFE). 20 hips were treated and followed for 12-24 months. Clinical and radiological outcomes improved significantly, with no cases of avascular necrosis or osteoarthritis. The approach was found to provide comparable results to modified Dunn procedure but without the risks of complications like avascular necrosis. It was concluded to be a preferred option for treating chronic stable moderate-severe SCFE.
Dr. Hooshang Saberi is a neurosurgeon in Iran who led the first team in Iran to successfully transplant Schwann cells to repair spinal cord injuries. The team has now treated over 60 patients, with about a 60% success rate of improved neurological function. Dr. Saberi was interested in this research due to seeing patients suffering from spinal cord injuries. He conducted animal studies to test the hypothesis that Schwann cells could promote repair in the spinal cord like they do in the peripheral nervous system. This technique uses only Schwann cells for transplantation and represents a unique approach compared to research in other countries.
Union Rate of Tibiotalocalcaneal Nail with Internal or External Bone Stimulat...skisnfeet
This study compared the union rates of tibiotalocalcaneal (TTC) arthrodesis using an intramedullary nail with either internal or external bone stimulation. The study found that the union rates were similar between internal (53%) and external (57%) bone stimulation. Additionally, the rates of successful fusion capable of independent ambulation were similar between internal (81%) and external (83%) groups. While time to partial weight bearing was slightly faster with internal stimulation, there were no other significant differences in outcomes between the two bone stimulation methods.
Robotic spine surgery is on the cutting edge of medicine, allowing our surgeons to exercise an incredible level of precision, well beyond standard capabilities.
Surgeon Performed Ultrasound Privileges, Competency And Practiceu.surgery
1) The document discusses the results of an ACS survey on surgeon-performed ultrasound privileges, competency, and practice.
2) The survey found that over half of responding surgeons use ultrasound in multiple clinical areas and many perform ultrasound-guided procedures, most commonly for breast procedures.
3) In general, surgeons reported competency with less than 20 ultrasound examinations in most clinical areas, except for the acute care setting which required 21-30 examinations.
Corrective measures lengthening of fourth brachymetatarsiaChris Lim
This study assessed three surgical techniques for lengthening the fourth brachymetatarsia: one-stage bone grafting, gradual lengthening with an external fixator after osteotomy with a saw, and gradual lengthening with an external fixator after osteotomy with an osteotome. The study had limitations including its retrospective design, selection biases, and inconsistencies in sample sizes and follow-up times. While gradual lengthening with an osteotome achieved the greatest length gain, the study's conclusions are limited by the lack of a clear hypothesis and controls for biases. Future prospective studies are needed to draw more reliable conclusions.
Instrumentation in cases of tuberculosis of spine Docdeng
This document discusses the management of tuberculosis of the spine using instrumentation. It begins by providing background on tuberculosis of the spine. It then discusses the rationale for using instrumentation in spinal tuberculosis, including to provide stability and allow healing without increased deformity. The document outlines the authors' experience using instrumentation in 18 patients with spinal tuberculosis of varying locations and neurological involvement. It describes the surgical approaches and instrumentation used. Post-operative imaging and outcomes including functional assessment are presented, showing good recovery in most patients. The conclusion emphasizes the role of instrumentation in minimizing deformity in spinal tuberculosis.
This document discusses the rationale for using stimulating versus non-stimulating catheters for continuous peripheral nerve blocks and summarizes the current evidence. It describes how stimulating catheters can help ensure correct placement but studies have shown inconsistent results. Ultrasound guidance has been shown to decrease placement time and failures compared to electrical stimulation techniques alone. While stimulating catheters may provide slightly better analgesia when correctly placed, ultrasound guidance is a good alternative approach. In conclusion, more research is still needed to definitively determine the advantages of different catheter placement techniques.
Ultrasound And Regional Anesthesia Feb 2009jimsparrow1
This summary reviews the key points from a document about ultrasound and regional anesthesia:
1. Ultrasound guidance for regional nerve blocks may provide benefits like faster block performance, fewer needle passes, and faster onset of blockade compared to other techniques.
2. Literature reviews found no differences in efficacy or safety between ultrasound guidance and alternative techniques for nerve blocks. However, ultrasound may allow for reduced local anesthetic volumes.
3. While no evidence shows ultrasound is safer, no studies found other techniques to be superior either. Overall, ultrasound guidance seems to provide certain advantages over other methods without compromising efficacy or safety.
This document provides an overview of a physical therapy course on total hip rehabilitation. The course objectives are to understand hip surgery and exercises, describe hip biomechanics, and effectively progress patients through rehabilitation. The schedule covers topics like evidence-based practice, anatomy, exercises, and outcome measures. Recent advances in hip rehabilitation include smaller incisions, reduced hospital stays, and early mobilization leading to better short-term outcomes. Assessment tools for hip function include the Lower Extremity Function Scale and Harris Hip Score.
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This document discusses ultrasound-guided injections for the upper extremity. It notes that accuracy of injections without ultrasound is quite low, around 30%, even among experts, and that ultrasound significantly improves accuracy. Studies show patients have less pain and better outcomes when injections are guided by ultrasound. The document outlines the sterile technique and equipment needed for ultrasound-guided injections. It provides images demonstrating how to perform various ultrasound-guided injections for structures in the shoulder, elbow, wrist and hand, such as the subacromial bursa, glenohumeral joint, lateral epicondyle, and median nerve.
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An Evening Webinar - Ultrasound Injections
1. An Evening Webinar Series …
Presented by Sacramento Orthopedic Center
Results Physical Therapy
Please be patient, We will be starting
shortly
Tonight’s Topic: Ultrasound Guided Injections
2. An Evening Webinar Series …
Presented by Sacramento Orthopedic Center
Results Physical Therapy
Ultrasound Guided Injections
3. Ultrasound Poll
• How would you best describe your experience with Ultrasound?
I use Ultrasound for all injections
I use Ultrasound for some injections
I have tried Ultrasound injections
I use Ultrasound, but not for injections
What is Ultrasound?
4. Alan M Hirahara, MD, FRCSC
• Medical director & Head team physician
– Sacramento State Athletics
• Head team physician
– Sacramento River Cats
• Publishes research and teaches nationally &
internationally
– Shoulder & knee arthroscopy, ultrasound, &
orthobiologics
www.HiraharaMD.com
5. Kyle Yamashiro, PT, DPT, CSCS
• President of private practice physical therapy clinic in
Sacramento, CA, RESULTS PHYSICAL THERAPY
• Affiliated with many Northern CA colleges & professional
teams
• Expert on rehabilitation following orthobiologics
• Presented nationally on this subject for over 10 years
• Worked together & written our orthobiologic protocols
www.ResultsTherapy.com
6. Alberto J Panero, DO
• Expert / International speaker in interventional
orthopedics & orthobiologics
• Core Faculty – UC Davis Sports Medicine
Fellowship
• Team Physician – Sacramento State University /
Sacramento Republic / Sacramento River Cats
www.SacSportsMed.com
7. Michael P Leathers, MD
• Fellowship trained in Sports Medicine & Shoulder Surgery
• Specialist in arthroscopy of shoulder, hip and knee
• Expertise in joint replacement of the shoulder
• Team Physician for Christian Brothers High School
Football
www.LeathersOrtho.com
8. Tonight’s Objectives
• Demonstrate how ultrasound can improve injection accuracy & patient
outcomes
• Introduce high quality, inexpensive point-of-care ultrasound units
• Discuss when to use cortisone vs. orthobiologics (i.e. PRP, Stem Cells)
• Show how a team approach to medical treatment & physical therapy can help
patient care
• Explain how to bill for ultrasound use to improve reimbursement
10. The After Party
• We will host a Zoom Meeting in my TeleMedicine Clinic
– Zoom: 9167323000 (No Passcode needed)
– Weblink: https://web.zoom.us/j/9167323000
– Connect from my website: http://www.HiraharaMD.com
11. The Next “An Evening Webinar …”
January 14th – Massive Irreparable RC Tears
Objectives
1. Explain the indications for reverse shoulder
arthroplasty
2. Present the outcomes from reverse shoulder
arthroplasty
3. Describe how early physical therapy yields superior
results in shoulder surgery
4. Discuss the history of the superior capsular
reconstruction (SCR)
5. Show how the SCR can be used to treat massive
irreparable rotator cuff tears arthroscopically
12. You May Be Really Good at Injections,
But Ultrasound Can Make You Great!
Alan M. Hirahara, M.D., FRCS(C)
Board Certified in Orthopaedic Surgery & Orthopaedic Sports Medicine
Specializing in arthroscopic shoulder surgery
AAA Affiliate – San Francisco Giants
13. Disclosures
The following relationships exist:
• Consultant
– Royalties
– Research & education support
• Consultant
• Medical Advisory Board
– Stock options
• Committee Member
• Committee Member
Arthrex Inc.
LifeNet Health, Inc.
Clarius Mobile Health
American Shoulder & Elbow Surgeons
Foundation
Big Sky Athletic Conference
14. Publications
• A Guide to Ultrasound of the Shoulder, Part
3: Interventional & Procedural Uses
– Hirahara A, Panero A
– Am J Orthop, Nov-Dec 2016
15. Ultrasound Improves Injection Accuracy
FICTION: Other physicians may miss, but I don’t!!!
FACT: Anatomical or landmark based injections often
miss their intended target
16. Society & Agency Recommendations
Ultrasound Guided Placement of Central Lines
• US Agency for Health Research & Quality (AHRQ)
– Shojania et al, 2001
• US Centers for Disease Control & Prevention (CDC) (2001)
• UK National Institute for Health Care Excellence (NICE) (2002)
17. Anesthesiology
Ultrasound – “The Standard of Care”
• Nerve blocks
– Reduces opioid use and need post-op
• Epidurals
• Vascular access or line placement
– Abrahams et al. Ultrasound guidance compared with electrical neurostimulation for peripheral nerve block: a
systematic review and meta-analysis of randomized controlled trials. Br J Anaesth. 2009;102(3):408-17
– Beaudoin et al. A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids
alone for analgesia in emergency department patients. Acad Emerg Med. 2013 Jun ;20(6):584-91
18. Procedural Complications
Central Venous Catheterization
• Van De Bos et al, 2011
• Iatrogenic pneumothorax
– Most expensive (Cost US healthcare
system $580 million in 2008)
– Lengthen hospital stay (4-7 days)
with additional cost ($45000/stay,
Zhan et al 2004)
• Fragou et al, 2011
– Ultrasound guided CVC
– Reduced PTX/HTX rates to 0%
• Vs. 4.9% & 4.4%
24. The Joint Space – Painful?
What Could You Hit?
• Getting There:
– Skin / Subcutaneous Fat
– Hoffa’s Fat Pad
• If you miss:
– Cruciates
– Condyles
– Meniscus
25. The Knee Joint – My Suggestion
4 cm
1.5 in = 3.8 cm
Suprapatellar Lateral
Approach, In PlaneSuprapatellar Lateral
Approach, In Plane
26. Knee Joint Suprapatellar Injection
Quad Tendon
Effusion / Joint Space
Fat Pad
Trochlear Bone
1 cm
1 cm
29. Accuracy of Shoulder Injections
• 30% of injections miss subacromial bursa – Experts
– Eustace et al, Ann Rheum Dis., 1997
– Yamakado, Arthroscopy, 2002
– Henkus et al, Arthroscopy, 2006
– Sethi et al, Orthopedics, 2006
• Naredo et al., J Rheumatol.,2004
– Randomized cohort (41 patients) to blind vs. U/S guided subacromial cortisone
injection
– VAS (p=0.001) & SFA (p=0.012) sig better in U/S guided group
34. Ultrasound Improves Efficiency
FICTION: Using ultrasound in my office takes too long!!!
FACT: Proper ultrasound incorporation for in office
injections adds negligible time and may be more
efficient
42. Reimbursement Comparison
Code Without / With Ultrasound
20600 / 20604
20605 / 20606
20610 / 20611
Payment Without / With Ultrasound
$48.51 / $73.81
$50.67 / $81.69
$61.45 / $94.51
Approx. 50 – 60 % Increase with Ultrasound
43. Publications
• A Guide to Ultrasound of the Shoulder Part 1:
Coding and Reimbursement
– Hirahara A, Panero A
– Am J Orthop, Mar-Apr 2016
http://www.mdedge.com/amjorthopedics/article/106568/imaging/guide-ultrasound-shoulder-part-1-coding-and-reimbursement
44. Ultrasound Enhances Treatment Options
FICTION: What I do works & I don’t need it!!!
FACT: Orthobiologics have changed treatment options
and new paradigms are required
45. Spectrum of Patellar Tendon Pathology
Rupture
Partial Tear
Fusiform Swelling
Normal
46. Corticosteroid Risks
• Soften or damage cartilage
• Weaken or rupture tendons
• AVN or thinning of bone
• Increase risk of infection
• Diminish activity of immune system
• Temporary increase blood sugar
• Soft tissue (fat) atrophy
• Crystal deposition
• Steroid flare
• Hypopigmentation
• Thinning of skin or soft tissue (locally)
Filardo et al, Knee Surg Sports Traumatol Arthrosc 2013
47. Negative Effect of Pre-operative Cortisone Injections on
RCR Outcome & Increased Risk of Revision
• Agarwalla et al, Arthroscopy, 2019
• Desai et al, Arthroscopy, 2019
• Forsythe, JBJS-Am, 2019
• Lee et al, KSSTA, 2015
• Maman et al, AJSM, 2015
• Traven et al, Arthroscopy, 2019
• Weber et al, Arthroscopy, 2019
• Werner et al, AANA Abstract, 2018
48. Number and Timing of Injections & Risk of RCR Revision
• Single injection elicits small risk of
revision
• Injections closer to time of index RCR
places patients at higher risk
• 2 or more injections places patients at
significant risk of revision
• Desai et al, Arthroscopy, 2019
• Forsythe et al, JBJS-Am, 2019
• Traven et al, Arthroscopy, 2019
• Weber et al, Arthroscopy, 2019
• Werner et al, AANAAbstract, 2018
49. Platelet Rich Plasma
• PRP in the literature, first described
– O’Brien et al, J Clin Pathol, 1969
• PRP first reported use following an open heart surgery
– Ferrari et al, 1987
• Exogenous fibrin clot for meniscal repair
– Arnoczky & Warren, 1988
• Ophthalmology uses PRP
– Kelly et al., 1989
• Dental community uses PRP in oral surgery
– Marx, 1998
• FDAApproves PRP for use in the US in 1999
51. Level I Evidence
PRP in DJD
PRP Superior to Hyaluronic Acid
• Cerza et al, AJSM 2012
• Sanchez et al, Arthroscopy 2012
• Vaquerizo et al, Arthroscopy 2013
• Chang et al, ACRM, 2014 (Meta-analysis)
• Cole et al, Preliminary data 2014
PRP Superior to Placebo
• Patel et al, AJSM 2013
• Chang et al, ACRM, 2014 (Meta-analysis)
• Smith et al, Preliminary data 2014
52. Level I Evidence
PRP in Patellar Tendonopathy & Partial RC Tears
Dragoo et al, AJSM, 2014
• 23 patients, RCT
• Patellar tendonopathy
• US-guided PRP-LR/needling vs dry needling
alone
• 12 wk f/u
– PRP with significantly better VISA score
– 25.4 improved vs 5.2 with needling alone
• No treatment failures in PRP group
Kwong et al, Arthroscopy, 2020
• 99 patients, Double blinded RCT
• Partial rotator cuff tears
• US-guided cortisone vs PRP
• @ 3 mos, PRP sig imp over cortisone
– VAS (-13.6 vs. 0.4, p=0.03)
– ASES (13.0 vs. 2.9, p=0.02)
– WORC (16.8 vs. 5.8, p=0.03)
• No difference @ 1 yr
54. 6 Weeks after PRP Injection
Sept 7 – 0.37 cmJuly 18 – 0.6 cm
55. Stem Cells
Proliferation & Migration Significantly Increased with PRP
– Kakudo et al, Plast Recontr Surg 2008
– Zaky et al, J Tissue Eng Regen Med 2008
– Drengk et al, Cells Tissues Organs 2009
– Mishra et al, Tissue Eng Part C Methods
2009
– Kruger et al, J Orthop Res 2012
– Moreira Teixeira et al, Biomaterials 2012
– Murphy et al, Biomaterials 2012
– Hildner et al, J Tissue Eng Regen Med 2013
56. MRI Analysis of Pelvis
• Hirahara, Panero, Andersen
– AJO, 2018
– Purpose: Find the ideal entry point & approach
angle for BMA from the PSIS
– MRI’s from 13 males / 13 females
58. Pearls to PSIS Bone Marrow Aspiration
• Use ultrasound
• Find medial aspect of PSIS
• Angle 24° lateral
• Avg distance to anterior
wall
– 6.74 cm (♀) & 7.53 cm (♂)
• Perpendicular: 3.2 cm
63. How Can You Get This Info?
• Youtube.com/HiraharaMD
– This webinar recording
• Slideshare.net/HiraharaMD
– My slides
• HiraharaMD.com
– This webinar recording
– Will post my lecture
– All references pdf copies
• References:
– Hirahara, Panero. A guide to ultrasound of
the shoulder, Part 1: Coding &
reimbursement. Am J Orthop. 2016 Mar-
Apr;45(3):176-82.
– Panero, Hirahara. A guide to ultrasound of
the shoulder, Part 2: The diagnostic
evaluation. Am J Orthop. 2016 May-
Jun;45(4):233-8.
– Hirahara, Panero. A guide to ultrasound of
the shoulder, Part 3: Interventional &
procedural uses. Am J Orthop. 2016 Nov-
Dec;45(7):440-5.
64. The Next “An Evening Webinar …”
January 14th – Massive Irreparable RC Tears
Objectives
1. Explain the indications for reverse shoulder
arthroplasty
2. Present the outcomes from reverse shoulder
arthroplasty
3. Describe how early physical therapy yields superior
results in shoulder surgery
4. Discuss the history of the superior capsular
reconstruction (SCR)
5. Show how the SCR can be used to treat massive
irreparable rotator cuff tears arthroscopically
65. An Evening Webinar Series …
Please Join Us for the After Party
After Party @ Zoom 9167323000
Next Time (Jan 14th): Irreparable Rotator Cuff
Tears
Notes de l'éditeur
Volk, Betty
Ed Cooper, Calcified Cartilage, Knee injection
Tanaka, Sharon
Macias, Maria
Kevin Thompson, Subacromial Injection
US gives us the confidence that we know exactly where we’re putting our needle tip and medication and takes out the guess work
Study after study after study
Even surveying experts who spend their whole days injecting joints, without ultrasound guidance, we are missing up to 50% of the time, even in these most skilled hands
Without ultrasound truly blind, and research strongly proves that ultrasound guidance improves our accuracy