Grand Rounds - Complex Cases Imagery

Winter 2012 - Volume 3, Issue 1

Case 1: Anterior Inferior Iliac Spine as a Source of Hip Impingement

Presented by Bryan T. Kelly, MD, and Gregory G. Klingenstein, MD
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Case 2: Surgical Hip Dislocation, Osteochondroplasty and Osteochondral Allograft Transplantation to Correct FAI and a Large Osteochondral Lesion of the Femoral Head

Presented by Ernest L. Sink, MD, Bryan T. Kelly, MD, Riley J. Williams, III, MD, and
Lazaros A. Poultsides, MD, MSc, PhD
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Case 3: Staged Bilateral Periacetabular Osteotomies for the Surgical Treatment of Hip Dysplasia

Presented by David S. Wellman, MD, Robert L. Buly, MD, and David L. Helfet, MD
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Fall 2011 - Volume 2, Issue 3

Case 1: Adult Traumatic Brachial Plexus Injury

Presented by Scott W. Wolfe, MD, and Kieran O’Shea, MB, FRCSI
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View the Anatomy and Physical Exam of the Adult Brachial Plexus Online CME Activity

Case 2: A Custom Triflange Acetabular Component for Management of Severe Acetabular Bone Loss

Presented by Mathias P.G. Bostrom, MD, and Michael B. Cross, MD
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Case 3: Management of Posterior Tibial Tendon Rupture and Severe Flatfoot Deformity

Presented by Jonathan T. Deland, MD, and Elizabeth Young
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Case 4: Bilateral Custom Femoral Stems in a Patient with Skeletal Dysplasia

Presented by Mark P. Figgie, MD, and Seth A. Jerabek, MD
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Summer 2011 - Volume 2, Issue 2 - Rheumatology

Case 1: Bilateral Knee Replacement in Rheumatoid Arthritis

Presented by Susan M. Goodman, MD; Linda A. Russell, MD; and Mark P. Figgie, MD
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Case 2: Systemic Lupus Erythematosus and Severe Pulmonary Hypertension

Presented by Lisa R. Sammaritano, MD; Weijia Yuan, MB; Kyriakos A. Kirou, MD, FACR; James Horowitz, MD; and Evelyn Horn, MD
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Case 3: Rheumatoid Arthritis Mimicking Pigmented Villonodular Synovitis

Presented by Michael D. Lockshin, MD; Alana B. Levine, MD; and Edward F. DiCarlo, MD
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Case 4: Tumor Necrosis Factor Inhibition Therapy for Sarcoidosis Presenting as Transverse Myelitis and Uveitis

Presented by Arthur M.F. Yee, MD, PhD
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Winter 2011 - Volume 2, Issue 1

Case 1: Osteotomy and Allograft Transplants to Restore Knee Articular Surface and Meniscus

Presented by Scott A. Rodeo, MD, and Clifford Voigt, MD
Click on any image to enlarge

Figure 1: MRI of the right knee demonstrating incongruity of the lateral femoral condyle at the site of the prior osteochondral autograft with loss of articular cartilage. Attenuated lateral meniscus extruded into the lateral gutter. Deformity of the lateral tibial plateau with diminished articular cartilage.	Figure 2: Standing hip to ankle AP x-ray showing valgus alignment of the right knee.	Figure 3: AP and lateral x-rays of the right knee after varus producing distal femoral osteotomy with osteochondral allograft resurfacing of the lateral femoral condyle as well as implantation of an osteochondral hemi-tibial plateau allograft with attached lateral meniscus.	Figure 4: Arthroscopic views of the right knee demonstrate the lateral meniscus to have normal size, position, and morphology with intact horn attachments. The articular cartilage on the osteochondral allograft in both the lateral femoral condyle and the lateral tibial plateau appeared intact. The junction between the osteochondral plug in the lateral femoral condyle and the surrounding native articular cartilage could still be discerned.

Case 2: Complex Primary Total Knee Replacement with Large Cystic Lesions

Presented by Amar S. Ranawat, MD, and Morteza Meftah, MD
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Figure 1: Figure 1: Antero-posterior (1A) and lateral (1B) pre-operative radiographs demonstrating diffuse joint space narrowing, joint effusion and large cystic lesions (red dots).	Figure 2: Coronal (2A) and sagittal (2B) T2 MRI images, demonstrating large lateral femoral condylar (green arrow), intercondylar (red arrow), and proximal tibial (yellow arrow) cysts.	Figure 3: Figure 3: Intra-operative finding of the cystic lesions (black arrowheads) on femur (3A) and tibia (3B).	Figure 4: Antero-posterior (4A) and lateral (4B) radiographs two years post-operatively showing proper alignment and fixation of both components. A sample of the tibial sleeves is shown (4C).

Case 3: Severe Traumatic Tibial Bone Loss and Bifocal Tibial Transport

Presented by Roger F. Widmann, MD, Arkady Blyakher, MD, and Vladimir Goldman, MD
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Figure 1: AP radiograph of left tibia demonstrating distal shaft bone loss and temporary fixation with monolateral external fixator system.	Figure 2: AP radiograph of left tibia demonstrating distraction at the two proximal tibial osteotomy sites and gradual transport of the tibial shaft toward the distal tibial segment. The distraction and transport are performed using the Ilizarov-Taylor Spatial Frame circular external fixator system.	Figure 3: AP radiograph of the left tibia demonstrates maturation of the regenerate bone at both transport sites as well as complete healing at the distal tibial docking site 18 months post injury.	Figure 4: Clinical picture of the patient at the end of treatment. Left lower extremity has excellent alignment, a plantigrade foot and equal leg length. The patient ambulates without orthotics or assistive devices.

Case 4: Management of High Grade Spondylolisthesis

Presented by Federico P. Girardi, MD, Fred Mo, MD, and Stephanie Ihnow, BA
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Figure 1: Preoperative sagittal CT scan showing Grade III spondylolisthesis.	Figure 2: Post-operative CT image highlighting the cage position traversing L5-S1.	Figure 3: Post-operative lateral x-ray of final construct from L4-S1 and posterior cage.	Figure 4: Postoperative AP x-ray of final construct.

Summer 2010 - Volume 1, Issue 2

Case 1: Neuropathic Joint, Total Knee Replacement

Presented by Thomas P. Sculco, MD, and Danilo Bruni, MD
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Figure 1: Antero-posterior radiograph of the neuropathic knee joint, secondary to diabetes mellitus	Figure 2: Lateral radiograph of the neuropathic knee joint	Figure 3: Antero-posterior radiograph after knee arthroplasty using a rotating hinge prosthesis	Figure 4: Lateral radiograph after knee arthroplasty using a rotating hinge prosthesis

Case 2: Open Reduction of Pipkin IV Fracture through
Trochanteric Flip Osteotomy

Presented by David L. Helfet, MD, and Devon M. Jeffcoat, MD
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Figure 1A-C: Anteroposterior (AP) and Obturator Oblique radiographic pelvic views and axial CT images through the hip joint (clockwise from top-left) illustrating a comminuted femoral head and posterior acetabular wall fracture.	Figure 2: Intra-operative photograph demonstrating trochanteric flip osteotomy performed through a Kocher-Langenbeck approach and reduction of the femoral head and posterior wall acetabular fractures.	Figure 3A-C: Postoperative axial CT images through the roof of the acetabulum and hip illustrating anatomical reduction and acceptable positioning of the hardware, and AP and Obturator Oblique radiographic pelvic views (counterclockwise from top) at six months following surgery reveal maintenance of fixation and joint space.

Case 3: Complex Limb Reconstruction Techniques

Presented by Austin T. Fragomen, MD
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Figure 1: A standing AP radiograph of both lower extremities shows a hyper-trophic nonunion of the left femur with varus (16 degrees) and shortening (8.2 cm).	Figure 2: A later standing AP radiograph of both lower extremities showing the Ilizarov/Taylor spatial frame on the left femur. Most of the length is restored and the varus is corrected to a satisfactory position. Note the double rings on the proximal femur used to prevent ring deflection. Also note the bending of the proximal half pins.	Figure 3: A final standing AP radiograph of both lower extremities demonstrates equalization of limb length and full healing of the both the femur and tibia. The tibial nail was later removed.

Case 4: Reverse Total Shoulder Prosthesis for the Treatment of a Four-part Proximal Humerus Fracture

Presented by Edward V. Craig, MD, MPH, and Lawrence V. Gulotta, MD
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Figure 1: Radiograph at presentation showing a comminuted proximal humerus fracture with displaced humeral shaft.	Figure 2: CT showing significant comminution of the greater tuberosity (arrow).	Figure 3: Modified Grashey AP radiograph at most recent follow-up.	Figure 4: Axillary radiograph at most recent follow-up.

Winter 2010 - Volume 1, Issue 1

Case 1: Simultaneous Reconstruction of Bone and Soft-tissue Defect

Presented by S. Robert Rozbruch, MD
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Figure 1: The patient underwent removal of the right intramedullary tibia nail, irrigation and debridement of the draining sinus tract of the tibia, and application of temporary external fixation.	Figure 2: A two-ring construct with the Ilizarov/TSF (Smith & Nephew, Inc., Memphis, TN) was applied with intentional deformation to allow primary wound closure.	Figure 3: An osteotomy of the proximal tibia for lengthening and addition of a proximal tibial ring were performed five weeks after the acute shortening. Gradual lengthening of 60 mm was accomplished.	Figure 4: At 12 months he had no deformity, equal leg lengths and no pain.

Case 2: Salvage of Bilateral Extensor Mechanism Failures After Total Knee Replacement

Presented by Alejandro González Della Valle, MD; Matthew S. Hepinstall, MD; and Jose Ramon Muiña Rullan, MD
Click on any image to enlarge

Figure 1: There is a palpable gap in the extensor mechanism of the knee.	Figure 2: Preoperative radiographs demonstrate chronic disruption of the extensor mechanism of both knees with an avulsion of the inferior pole and proximal migration of the patellae.	Figure 3: Intraoperative photograph demonstrating fixation of the tubercle allograft in the tibia with two titanium screws and suture of the native quadriceps tendon to graft with the knee in full extension.	Figure 4: Four month postoperative radiographs demonstrate intact bilateral reconstructions with stable allograft.

Case 3: Severe Early Onset Kyphoscoliosis

Presented by Oheneba Boachie-Adjei, MD
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Figure 1A & 1B: Pre-operative photographs of the patient showing the severity of the scoliosis and kyphosis.	Figures 2A & 2B: Preoperative AP and Lateral X-rays show a severe and rigid scoliosis (130 degrees) and hyperkyphosis (130 degrees).	Figures 3A, 3B, 4A & 4B: Postoperative photographs show the balanced correction achieved in the frontal and sagittal planes.

Case 4: Treatment of Massive Pelvic Discontinuity with a Custom Triflange Acetabular Component

Presented by Mathias P. G. Bostrom, MD
Click on any image to enlarge

Figure 1: Pre-operative AP radiograph	Figure 2: CT scan demonstrating large fluid collection displacing pelvic vessels	Figure 3: 3D reconstruction of CT scan	Figure 4: One year post-operative AP pelvis radiograph