post acetabular fracture - post milch batchelor osteotomy

Case for opinion-
This 52yr old gentleman had girdlestone followed by shanz ostetotomy in 1995 for neglected fracture dislocation left hip.
Now he complains pain around same hip and wants THR

Bloods are normal
The senders  plan is for uncmented Depuy ceramic on poly with S-ROM stem.

Will he need Subtrochantric shortening Ostetotomy?

 

My view is

1. I need judet view/CTscan to see the acetabulum the posterior colum and wall in particular

2. intraop specimens for frozen section and culture

3.Looking at the AP a primary acetabular cup is possible.

4. I wouldnt do an SROM as in a similar case the corrective subtroch osteotomy went in for nonunion as SROM is essentially a distal fitting stem  and the hold on the distal fragment is not rigid as a distal loading stem like Solution or Echelon

5. You wouldnt need a shortening most likely but would correct the deformity where the central axis of the proximal fragment(Red Line)  reaches the medial shaft- an opening variety(ORANGE IS THE LINE OF THE OSTEOTOMY PERPENDICULAR TO THE RED LINE) and ream and hold the distal fragment tight with solution or echelon COCR stems . graft the result defect with the cancellous graft> plrase strip the v lateralis only at the osteotomy keeping the  muscle  through a vertical split maintaing the the  extramedullary blood supply of the distal fragment. 

TKR in postraumatic stiff painful knee

 63 yearold  lady with post traumatic arthritis- 5 years post open type 2 fracture tibia  treated primarly by illizaro and  screw presented with pain and 0 10 to 30 degress rom. No sinuses. ESR and CRP normal.. Multiple scars on the proximal tibia as sequelae of open fracture. Never had sinuses postop. Piperacillin- tazobact  with CAPO4 pellets were introduced into tibial canal  to combat bugs if any and a fractional lengthening of quads was done.to obtain 100 degrees flexion.

 We used an offset stem. Long stem was avoided so as to avoid further osteotomy inscisions as well as to avoid exposing the luscent ares of tibia.

 Introp frosen section and leucocyte esterase tests were negative.

33 yer old male post osteotomy for opinion from dr. rajesh

Ensure that the pain is from the hip itself as the lateral joint space is reasonable although inferiomedially it looks narrower. If in doubt put  local in the hip and reasses pain relief. 

ANY takers for FAI here- SCOPE and proceed

 If a THR is planned 1would consider the follow Problems including  insitu implant- remove the scews  after dislocation to avoid intraop fractures. the plate can be left alone. sometimes one might be able to put a small stem between the screws in cemented situation. Send intraop cultures

 the stem  should ideally be longer then the plate to avoid postop fractures.

some doctors use  preop SWD to heat the implant to loosen it preop, other heat the screws with the cautery to loosen the screws.

keep broken screw removal kit in case of problems and include the philips head screw driver  incase of older generation screws

2.  Varus neck with a shorter neck. bigger offset stems  would help to maintain the abductor tension as well as to prevent lengthening in case of  using a hard on hard bearing obtaining a tight reduction and avoid stripe wear.

 longer  stem preferbly modular proximal loading stem like SROM to make revisions easier in case of  ceramic head fracture. one could use a longer cemented sem like exeter with offset options.

3. avoid introp and postop fractures.

as far as your questions on entry point to avoid varus stem.

I would extend a line proximally on the xray as shown below from the medial edge of lateral cortex of the diaphysis and measure it from the lateral trochanteric cortex(orange Line) to make it your starting point introp. some companies have a lateraliser instrument to further lateralise the entry.

good luck