Femoral stem is jammed thru the cortical window, porotic bone and and ofcourse the mushroom shaped acetabular cement mantle.
plan
ETO, 2 stage revision, mobile spacer Plat
e back up in case of fracture as the bone is porotic. Vascular back up and Ilioinguinal exposure plan ready in case of iliac vessel bleed. Angio with limb movement to see if any kinking occurs. As planned we had all the problems execpt vascular injury. We used a plate to tie the ETO stabilising wires as the cortex was too thin to hold the wires. Iv antiobiotic was given for 6 weeks followed by oral rifampicin. Subcutaneous forteo was given to improve bone quality. she did not return for the second stage revision. My worries include further acetabular bone loss with abrasive wear, breakage of the spacer and rarely dislocation. May be a static spacer could avoid these problems. Sorry, I just heard she had a stage 2 revision elsewhere and is walking.
Would like to know of what type of cement spacer was used…heard of PROSTALAC...spacer G, Antiloch and antibiotic coated Rush pin.. and also the spacer for the acetabular side…?
ReplyDeleteDo we really need to do an ETO…?since there is already a window(Similar to the scaphoid window of Kerry) through which the implant exited inferiorly though it is medial…!Looks like the implant is loose..
Do you look for serum bactericidal concentration prior to 2nd stage revision or hip aspiration after stopping antibiotics for 4 weeks…?
Does the spacer contain vancomycin or tobramycin with Palacos G…?
sorry to pose so many questions...
hitesh
Spacet is a an articulated one made by exatech. all the mobile spacers maiantain the soft tissue tension and one can mobile immediately but the risk of fracture. dislocation and acetabular wear are problems one has to keep in mind. static spaceres avoid these problems and one can choose any heat stable antibiotic of choice. we used tiecoplanin a few cases. Tobramycin powder is not available in the country any more. Is palacos availble preloaded with tobramycin? I know that palacos has better eluding properties.
ReplyDeleteAs far as the ETO is concerned we chose it to avoid fractures as the bone was too porotic( Glass like) the shadows could be seen intramedullary. Inspite of which we had fractures.
jacob
excellent work sir..what cud be the option in 2nd stage?S-ROM for femur and reconstruction cages for acetabulum...would u like using the dysplasia cup for better fixation, since the superior acetabulum looks okay though i can see some radiolucencies...
ReplyDeletechecked various product catalogues cudnt find tobramycin with palacos..only simplex from stryker has tobramycin...all others including biomet have genta..
That good to note that there is ready made tobramycin with simplex. If i remember correctly, i felt a jumbo cup with >50% posterior and superior contact(ideally 70%) was suffient. I use a cage only in posterior column defects. I have not used a dysplasia cup ever even in dyspasia
ReplyDeleteany role for pre OP CT angio to rule out erosion of iliac artery...?
ReplyDeleteI do something very different. I do an angio and move the hip to see if any kink occurs while moving to see if any adhesions are there. these occur more in women and in infected cases statistically. Thank god, i have not been caught out yet in 4 cases to date
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ReplyDeletepeter kay at wrightington never did ETO in more than 1000 hip revisions...!!he uses an ultrasonic tool for implant removal..
ReplyDeleteSurprisingly he never uses more metal, he tries to preserve biology using impaction grafting...
Sloof's method is great in a few centers with lots of grafts in the bone bank. BONE quantity is limiting factor. Re-revision rates in impaction grafting cases are good only in 3 centers with Writington below others like exeter. There is no gold standard in revision yet for that matter even in primary. there are many ways to skin a cat.
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