Finally after all the comments. Lets show you what happened. The patient is financially challenged and has INR 10,000. We collected around and decided to revise the the worn out acetabulum as that was causing more pain. Our plan was to remove the bipolar and remove the distal broken stem through a knee arthrotomy and punch it out through the intercondylar notch with an oats recipient instrument induced access. Unfortunately we found some clear fluid from the hip and therefore did not want to contaminate the knee. While waiting for the frozen section, cell count and g stain we did a femorotomy and removed the distal implant. As the femorotomy reached the diaphyseal flare we had to choose a locking stem in this case Reef(HA coated) with ceramic on ceramic bearings . she is mobilising with a single stick now and now wants revision of the dislocated hip which possibly could be done with a primary stem with a large bearing. I would be glad if there are any takers for doing the same as she is broke. She would about 200000 for HARD ON HARD LARGE BEARING THR.The first surgeon who is an orthopedic hospital owner apparently has washed his hands off and lives a semiretired life comfortably.
Points for discussion.
1. Rule out an metabolic cause in a 36 yr old female with bilateral # nof.
2.Adequate fixation of neck of femur. DHS is easy with a derotation screw. A gamma nail may be more indicated in elderly.
3. No role for hemi arthroplasty in young active patients even if financially challenged.
4. Does IMC need to debar and penalise the criminal who did this?
jacob
Points for discussion.
1. Rule out an metabolic cause in a 36 yr old female with bilateral # nof.
2.Adequate fixation of neck of femur. DHS is easy with a derotation screw. A gamma nail may be more indicated in elderly.
3. No role for hemi arthroplasty in young active patients even if financially challenged.
4. Does IMC need to debar and penalise the criminal who did this?
jacob
36 yr old female auxillary nurse sustained what appears a bilateral # neck of femur ( ?metabolic cause) had the following set of surgeries done free by I believe an orthopedic surgeon. The final xrays before revision is on the left and what serial xrays available are below. your comments on what was done and what to do?
Thank you, Jacob for starting a site, where like minded people can communicate.
ReplyDeleteThe pictures that you have shown demonstrate the work of someone, who not only shows his lack of expertise, but also shows the unwillingness to accept one's limitations. Such people will never refer the case to another surgeon, capable of dealing with that. This can be called "surgical assaults". Such people are many among us and we will continue to see many such cases.
Thank you sir
Deletesir, though not fully unrelated to this..i was wondering wht are the present day indications for the "head salvaging" surgeries like valgus osteotomies, muscle pedicle grafts, vascualrized fibula and all in non union / delayed union # NOF?
ReplyDeleteGreat that you brought out these points.
ReplyDeleteTo salvage the head if avascular, free vascularised pedicle grafting or local vascularised pedicle grafting is an option provided one has the skills for the same. Most articles which propose the same are level 3 or 4 articles with dubious objective assesment. I do believe valgus osteotomies are definetely indicated provided the patient understands the limitations and are willing to take the chance which have close to 60% chance of success if done right and the head is vascular. In this day and age you want to do an operation with a high chance of success and easy to reproduce. The greats who proposed the same are few and still few who are operating now.Our patients today ask for 100% success rates which no mortals can provide. The technical difficulties in converting a failed salvage operation are moderate and can be still a success if planned and executed well and if one has not burned the bridges with an infection.
Hello Jacob, its me sanjay.
ReplyDeleteMy comments on the first surgery- I would have chosen DHS, instead of a nail, b'coz it is a # NOF and it is biomechanically superior in cadaveric studies when compared to Screws. Also, using a PFN / Long nail, could risk damaging the vessel increasing the chances of AVN (upto 4% in studies for IT #)and risking displacement of fracture during nail introduction.
What i presume has happened is varus reduction to start with and then placing the cephalic screw too superior, that is why the fixation failure. I would not do an osteotomy for a primary case of #NOF (in this case the Pauwells angle is favourable.
After it failed the second surgery, was ill conceived- should have tried to acheive valgus reduction and convert PFN to DHS, instead of trying a miss a nail screw. Again failing to improve the the local biomechanics.
Third surgery, even more a disastor- A cemented fenestrated probably INOR bipolar in a 36 yr old, criminal and negligent. Would have considered Valgus intertrochantric osteotomy with 150 degree DHS in Fix before considering THA (cemented / uncemented). After the bipolar failed and fatigue fractured, should have definitely done THA, with removal of broken stem. I would have definitely referred the case to lakeshore hospital before the third surgery, atleast made a few calls call help. Bye.
Its great this bloging, hope to hear from you soon. Read your mail.
Sir, i just saw this case once again. I agree that whatever the first surgeon has done is wrong and very bad.But still, i dont think he deserves to be called a CRIMINAL. i would say that he is negligent and ignorant. Also revealing crucial patient information to the public, that would jeopardise the life of another fellow orthopod(however bad he maybe),to my thinking is not right. Sorry for being blunt.
ReplyDeleteIsn't negligence costing the patient lakhs of rupees, loss of work bad enough. I think the association should present a white paper on each conditions with options acceptable in any given case so that one does not have to defend the indefencable. My blog is essentially accessed by orthopods as a learning and discussion tool. Are we like commrades defending the con men among us. Act of commision are indefensible. This is a series of bad surgeries 6 in total with absolute ignorance.
ReplyDeleteHI Dr Jacob
ReplyDeleteDo you provide treatment for plantar fascitis?
The best options are to use a Plantar fascitis night splint( Pic and website- http://www.amazon.com/Plantar-Fasciitis-Splint-Medium-7-5-10/dp/B000EM6ZHQ/ref=cm_lmf_tit_12/189-9453439-3764524) and do strtching exercises of tendoachilles and fascia which your local physiotherapist will do. If it does not work in 2 months i would consider an injection. At 6 months to one year . if not relieved consider arthroscopic or open release of the plantar fascia
Delete