Procedure specific competence

Competence of doctor for specific procedure should be assessed/certified before new procedures are attempted. Our patients are not Guinea pigs to be practised on. Where has the Hippocrates oath we all took gone? Are values diluted by politics, religion and greed or just a reflection of the society we live in. I do believe patients have every right to see clinical audits from the department concerned before being subjected to  procedures.

 

Most Hospitals pay lip service to quality control. How on earth can a doctor see 100 patients a day? Are patients fools to believe that spending 5 mins with a patient is enough to  plan his complex management?. Of course per unit costs will go up. Isn't qualty worth the costs. When will our patients understand the con some of our "god like doctors " do in the name of medicine?. The PR will put many a  film star to shame. Marketing self, hospitals and products is the mantra of  the day. Protected time for physicians  for audits are necessary. May God help our profession,patients and world at large.

MPFL anchor points to the red spots

Patella tilt post TKA

My colleague Dr gnanavel has just come out with a paper  that a patellar tilt of more than 10 degrees might be associated with poor out come in TKA when patella specific scores are used to predict the outcome. He suggested that it would  be advisable  to use patellar specific scores in all future studies investigating the ever controversial patella in TKA. So consider merchants or skyline view and melbourne scores to asses anterior knee pain which is ever present if you ask for it in 10 to 30 percent of individuals.

fracture neck 6 yrs post resurfacing arthroplasty

              I was asked what to do next.

It appears the the femoral  metaphysis is abnormal. Is it an old infection or something else? The safest option would be a complete revision to a ceramic on ceramic bearing or ceramic on vit e poly in view of the bad press with metal on metal. The comonest cause of failure at medium term as above is if the primary indication was in AVN. One could consider one of the short stems in the market today like metaphyseal engaging short stems from metha hip from aesculap, silent hip from depuy, taperloc,balance microplasty to avoid the canal compromised deformed metaphysis.But remember these microhips have at best  year results in expert hands.

one needs to be careful to avoid loosing more acetabular bone while explanting the cup. May be the zimmer explant system would help.

MOM bearing in revision - 6 year followup of a type 2 acetabular defect in a 57 year ld lady

 

Chasing the good bone- medialisation to chase the good bone. high hip center 

6 year followup- clinically asymptomatic

Stress shielding

 

2 month old infected supra-intercondylar fracture in a 62 year old diabetic

 

 Infected, with multiple organisms, initially with gut organisms like klebsiella, providentia , E coli etc. Antibiotic treatment ended with pseudomembraneous colitis. They debrided him twice in the OR. The last organism was pseudomonas which was sensitive only to colistin, which he received. Discharging sinus still present

 

 What next

.1 Illizarow in capable hands

2. one final debridement with local stimulan beads with colistin and other "necessary" antibiotics with autologous bone graft  provided the fracture is stable.

any other suggestions welcome

6week old fracture in a bed ridden 92 year old lady

Any comments on mangement of this fracture in a 92 yr old bedridden patient post CVA with bed sores presented to an orthopedic colleague. any comments on manging this case provided the reatives are willing to take the risk.

 

 

1.  Leave alone on splint and analgesia. Cons- die in pain for the last days of her life

 

2.Excise and one stage distal femoral tumour prosthesis. The cons include cost, infection risk and fracture above the stem as well as intraop cement related problems. pros include quick surgery and can  mobilise if ever possible.

 

3. Indirect reduction- supracondylar nail with an addtional locking plate with or without cement to enhance stabilty

any other suggestions are welcome



painful hemiarthroplasty

 

 

 

 

 

 

 

 

 

The pain could be in the groin or thigh. if there is no rest pain it has to be as expected aseptic loosening. I would hesitate to put an uncemented AMP in a physiogical 60 as all evidence points to a THR can get better results if there is  no dislocation

                                                                                                 

One needs to rule out infection with the CRP/ ESR with aspiration and luecocyte esterase test. if not infected a one stage THR. My choice would be  to  do an uncemented cup with vit E poly,36 head and an uncemented fully HA coated  high offset stem if i can get good fixation. I need the opposite HIP xray to measure the offset -green line. if cemented stem is used consider roughening the endostium to  get cement interlock.

 

send at least 6 cultures of tissue,fluid in bactec as well as  check for fungal cultures( remember the cheatles forceps used in some ORs which need to be banned).

End of stem pain in a rev tkr

 This 67 year female presented with start up pain in the knee and midshaft of tibia which was tender. She is close to 2 years post revision.
The pedestal at the tip of stem and circumferential loosening line around the stem and medial tibia suggests that its loose. Awaiting bone scan.
Beware of straigth long tibial stems

My options
1. Revise the tibia  and use a shorter thicker uncemented  stem may be  70 mm Into 16 mm ending at least an inch above the present tip( no scratch fit).
Centralise the reamer with at  sleeve( the type we use for distal cement drilling in  revision stem) pass the  im nail centralised guide wire with an image check and use a central stem.if one is closer to the tip you would need to by pass the end of stem and then might need a curved stem or might get away with a slotted stem.
2.Use a short cemented stem
Ps . I have got away once with a cemented long stem in a RHK knee

break from the present

 Hi,

 I am taking   a break from the present job at LORC  and will return end 2014. In my stint at lakeshore I learned and practised orthopedics to the best of my ability with a team of colleagues  who pushed me further, with staff who took great care of my patients and help collect data and gave critical contribution to improve our quality of care.  Thank you team it was a pleasure working with you and hope to in future. I am sure what we started together,  will be taken up  higher by all of you.

 

 

Any cases mailed  will be replied on the blog without naming the sender unless mentioned.. If you don't want to please mention in the mail. I am not sure whether I will be able to upload cases from the new place i work in oman. Thanks for all the comments and hope at least some of the blogs were useful

jacob