postop cup migration in a RA osteoporotic patient

immediate postop

after postop mobilisation

This X-ray was send to me for an opinion. The initial X-rays were fine execpt for  some medialisation which in nonporotic bone would hav been fine.. On mobilising the patient complained of pain and the X-ray revealed the above.  It appears that the cup has migrated superiomedially suggesting a anterior column deficiency, but if the ilioischial line is traced up there appears to be a break sugesting posterior column breach.  Is it a T fracture.

   

First of all one needs Judet views and a ct to confirm the same. The options on table should include acetabular plates if the posterior column is compromised. A birch schnider cage if the posterior column is breached .if only the anterior column is breached one  could get away with a primary cup or a ganZ  cage and a cemented cup

Any comments or advise

 Our window for revision was 5 weeks later as the patient got chicken pox and had to postpone the revision  which increased the risks for bleeding dur to callus as well as reduced thr chances for  reduction of the T fracture  and plating. she also has a low pulmonary reserve and gross osteoporoisis. At revision we found a rotated maluniting posterior column a central/floor  defect. We elected to accept the deformity and bridge the defect with a BS cage with the inferior flange modified to a hook on table adding strength froM the tear drop( hope the flange does not break)  and cemented the cup and stem.  the stem is definitely in varus and the cementation could have been better . i do hope for a 10 yrs survival or more as she is low demand. we have started her on PTH  and VIT D.

 As a word of caution, beware of the severely porotic RA patient. using an uncemented cup is fine( if good bone stock is available) but watch out for fractures intra-op and may be postop. a cemented cup protected by a ganz cage or an antiprotrusio cage  could avoid a surgeons nightmare.

Tigth rope button stuck in the femoral tunnel

The white threads of the tight rope accidently got pulled with the button getting stuck in the  femoral tunnel(entirely my mistake) I believe. No amount of traction proximally or distally could dislodge the button as it got jammed in the femoral tunnel( check lateral view above .we got away by using a  suture button at the femoral exit. Has anyone had a similar  problem. Can the tight rope one e shortened be lengthened. . I couldn't  do anything as the button was well fixed in the cancellous bone but could not risk leaving this alone. Hence the suture button . Any comments or advise please

Tenoscopy

Synovial fold mimicking a tfcc tear

 Patient presented ith ulnar sidedpain post trauma. MRI revealed tear. scopy revealed a synovial fold mimicing a tfcc tear. removal of the fold relieved his symptoms

41 year old male with morning stiffness

The questions raised is whether there is any role for a valgus osteotomy/ hip arthroscopy.
Please comment
My views
1. adduction xray to check whether the joint space is maintained  and congruent in adduction to see the result of abduction osteotomy
2.Would A hip scopy would help map the joint cartilage to asses the wt bearing cartilage post osteotomy by assesing the cartilage in adduction as well as a chelectomy as the same time. My hip scopy experience to date is at best average
3. At present with my experience i would wait till pain develops to do a THR COC to get him > 20+ years when needed.
any other comments

failed bipolar with protrusio

 A case send for opinion. elderly person with painful hip.  Pardon the poor qulaity pics

Problems.
osteoporosis with protrusio
well fixed stem
Anterior column penetration

Solutions
1. Hip has migrated superiomedially suggesting anterior coloumn penetration- Posterior column intact hence a primary cup is possible as good posterior bone is available. CT scans could delinate if needed.( superiorlateral migration suggests posterior column penetration)
2. Dislocating the hip  from posterior  will be easier as an anterior or anteriolateral approach will make dislocation difficult- my choice will be posterior approach. Gentle dislocation with a hook. If difficult do an ETO to remove the stem and cement and use any distal loading stem
3. Would treat the patients osteoporosis too- consider PTH. Any reports on strontium in the presence of uncemented THR.
4. Would anyone consider primary cemented THR is such osteoporotic bone as  I have seen quite a few bipolar migration is severe osteoporosis any comments
 

Anterior impingement of ankle

 

 

 Patient with anterior pain on dorsiflexion exacerbated with anterior joint line presssue. Anteriomedial oblique xrays show the impinging osteophyte

arthroscopic management of meniscal root avulsion

 The issue if a menisectomy is done for root avulsions the chance of OA increases much higher than a partial menisectomy invoving the body. hence currently the advise is to repair them and protect the repair without wt bearing fo 6 to 8 weeks. It this case may be 2 sutures would improve the hold

Failed ACL reconstruction

Any takers on management and technique

 My options given to the patient.
 1. Scope remove the intra articular screw ASAP and do a revision ACL. However I warned him that in case of severe OA one might consider not doing an ACL. One could envsage problems only with the tibial tunnel screw. I plan to the tibial tunnel entry more medial exiting at ht lateral half of the medial tibail spine. Femoral tunnel isnt a problem as the previous tunnel is vertical.


Post op pics are below. The screw had damaged the medail edge of the lat femoral condyle adjacent to the notch( Like a wide notch plasty)

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

Ossron(cultured osteoblast) in AVN hip

Above is the xray of a 28 year doctor with pain in lt hip of 3 months duration. The mri showed a gr 2 lesion in lt hip and grade 1c rt hip. We attempted acteocyte culture and at 5 weeks the postop xrays are below. We are awaiting MRI pics to look at revascualrisation. His symptoms are better but that could be due to decompression alone.

 pleasantly surprised

 

Complex Hip- OA with intertroch nonunion with implant in situ

Any takers for this complex hip pics send to me by my good friend 

 He managed put a stem  between the screws had a problem with the  osteopenic trochanter and possibly cup both of which could contribute to instabilty which is what happenend  in time

 Charan whats the problem now and solutions
 as expected  the hip dislocated

The options now
The cup appears too anteverted as well as vertical. . with a flying trochanter adding to the problem.

 my advise is to revise the cup. use larger head if possible and use a trochanteric cable plate.if the troch is too soft to hold  wire over a titanim mesh. if this does not work only a capture cup or a tripolar head is the only solution.

My friend revised the cup and stabilised the hip. his trochanter has dissapeared. In this situation anchor the glutea to the reamaning bone or if that is not possible anchor the two flaps of TFL  to bone  leaving the distal portion free to inset distally. Abductor bace for 6 weeks

11 years post Single bundle PCl reconstruction

 I had the pleasant surprise of  reviewing a patient 11 years after a single bundle Quads tendon isolated PCL reconstruction done while I was at amrita institute. He has no symptoms and works as a project engineer in the oil feilds of oman.
o/e.
PCL was close to gr 2 solid end pt. no meniscal signs or joint tenderness Dial test negative. Xrays show minimal medial compartment narrowing as compared to the normal side. No patellofemoral changes.

Inspite of old technique the PCL recon was worth in a young man. I believe the present day literature support even in isolated PCL injuries more than grade 2.

My