Is this divergent hip dislocation

This radiograph was shared with me  by a colleague. Rt anterior dislocation and Lt posterior fracture dislocation in an RTA.  I have never seen this kind of an  injury before. Apparently he was thrown  off a  moving vehicle and succumbed to his

injuries before orthopaedic intervention..  The direction and magnitude of force  and position of limb at the point of impact determines the injury. The dash board injury and the boat injury combined as described historically

4 yr old painful bipolar arthroplasty in a financially challenged patient referred for opinion

Problems. 

Need a lateral X-ray of the distal stem to see the curvature as well quantify the erosion

I Do not have the patients age 

Financially  challenged patient

Loose stem and possibly cement mantle

Distal long cement mantle

 Medial cortical erosion at the distal end of site

?. Acetabular superior erosion

Hopefully no infection- to be ruled out by preop markers, LE  test and intraop frozen sections and cultures

 A THR is the only option. The  cost of the stem may be the compromise.  I would not use a cemented stem unless you can roughen the smooth endosteal surface abraded by the cyclical stem movement with a broach or burr for cement macro lock (difficult) or if one is good at impaction grafting and a cemented stem ( demanding in technique and patience).

Solutions

 Easy explant with proximal cement mantle and insert a tight fitting HA coated stem like corail after broaching complete removal of proximal cement mantle only and the stem should stop short at least 2 cm above the medial cortical defect - the problem of a peri prosthetic fracture  is real. 

Will a lateral by passing plate to protect the erosion with proximal wires and distal screws help in the compromise. One needd to wait and see. Would local bisphonates  or osteblasts help?

 There used to be a short grit blasted cone  stem by Wagner   With which I had revised in 2002. Iunderstand that zimmer takeover  of Sulzer orthopaedics  killed it.

 Ideally you need a long proximal loading distal fitting stem if the distal cement mantle can be removed  without an eto.  If not an ETO, take the distal cement mantle  and one should get 6 mm of distal scratch fit with a  poor coat stem like solution or even echelon. Template first please

supracondylar nonunion in 62 year old RA patient

This case was  refered for opinion by a colleague from india. Any advise is welcome.

 

My suggestion would be to go for cemented Rotating hinge with distal femoral reaplacement if the nonunion is confirmed intraop. In case there is evidence of  significant stable union I would consider a stemmed,sleeved varus valgus contrained knee aiming for 10 to 15 year survival