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

18 year old adolescent footballer with Ankle pain

He has pain on dorsiflexion anteriorly  and posteriorly on plantar flexion both of which are grossly limited

options please

I am planning on both anterior and posterior scopy of ankle, removal of loose bodies and osteophytes and viscosupplimentation.  Cannot expect complete relief in view in joint space narrowing

 Post op pics today

foot and ankle problems and solutions

http://www.ankleplatform.com/.  Check this website by dr. Van Dijk. He has done a lot to popularise current methods of management of foot and ankle problems. Would recommend his course to any upcoming foot and ankle surgeon as well as general orthopod

Type 3 periprosthetic fracture Lt hip

 Patient a 78 year old hypertensive underwent bipolar 8 months back elsewhere and refered to my friend for mangement with a periprosthetic fracture after a fall. There is a doubt about peri-operative infection

\

Problems ansd solutions/ 
1. ? infection- Hip aspiration being done for cultures as well as leukocyte esterase test( ref Parvizi guidelines in aaos). if we get the bug even if infected would do one stage with local antiobiotic delivery of choice with HA granules or Calcium phosphate granules both of which are commercially available. 2 stage may be too much for a 78 year old.


2. Widening distal canal compromising regular cylindrical distal fixing stems unless stems locking stems like REEF or aescalup are use. I understand there is an local long stem unipolar with locking available but is a stem with no coating and is a long stem austin moore  for those who want to use it. I do not have faith in these stems.
Solutions.

Modified wagner osteotomy( Anterior) ref pic Above makes quicker sand easier operation. In this case i would prefer it to ETO. Cement and uncemented stem distally and use a bipolar head. The osteotomy helps to cement distally easily as well as remove the stem without further collateral damage. Remove the distal porocoat with a carbide burr to have better cement bone fixtion  as compared to cement implant and  hope fully avoid early loosening. ( my longest follow up for simialar case is 5 .3 years in a n 80 year old- will put it up if I can find it in my blog). If successful we could mobilise him FWB day 1 postop

3. if a high demand patient one would need to use an uncemented long HA of grit blasted stem like REEF or Aescalup stem the name of which i have forgotten

Good luck
jake

Comments by the surgeon

Hip aspiration didnot yield anything yesterday. No frank pus seen. Frozen- 10-12 neutophills. tried to dislocate first but invain. did wagner osteotomy. put in HAP granules into the distal fragment down the canal , after centrifuging it in arthrex machine with polymixin B and vancomycin . Took off the distal coating with burr. 1.2  teicoplanin was mixed with 60 gm.Unfortunately put in the cement a bit early before doughy stage  . Hence was a bit difficult to put it in.

Abt 8cm cement mantle seen in the distal fragment  from the fracture site.

Hap with antibiotics packed in at osteotomy sites and gaps proximally

I would  go PWB to FWB  as comfortable as the cement mantle is at least 8 cm  and what prevents will the pain at the fracture site.

scaphoid nonunion

35 year old rt handed office assistant fell down 3 months back. He was advised surgery by the attending orthopod but refused.  returned 3 months later with the following xray

It was planned for a percutaneous grafting and herbert screw as described the late Dr. Slade. Unfortunately the graft introducer was bigger than the proximal drill hole. The plan was to put the percutaneous wire proximal to distal Drill(red line) the proximal fragment with a larger drill (green line)to put a custom currette thru the hole and currette the cyst and bone graft the cyst with  cancellous grafts thru the custom graft introducer similar to a bone marrow aspiration needle and compress the the fracure with a herbert screw. Finally only percutaneous compression with a herbert screw was done and at 4 weeks the fracture appears to be joining.   Ideally the deformity should be corrected and graft should be used. Luckily this is uniting

TKR iwith a bowed femur

 78 year old lady  with pain in rt thigh and knee. On Investigation her Vit D levels were low, Bonescan picked up the stress fracture. After 3 months of Vit D and PTH a tkr was planned

The limb axis films showed a 12 degree femoral bow.

Options
1. Navigated TKR
2. Custom jigs

3.What  are the options if both are not available

we did a lateral entry with the standard 5 degree femoral jig with a short rod to get the 12 degree cut.
 Navigation or custom jigs are the other options
below is the post op xray. Unfortunately the full length xrays are not availble will update it when she comes next time.

posterior ankle pain- painful os trigonum

Patient presents with posterior ankle pain. Sharp Plantar flexion and external rotation causes pain . Xray confirms a large fused os trigonum and MRI shows the associated inflammation

 A local injection can be used to confirm the same.
traetment involves  hindfoot scopy and excision of both the synovitis and os trigonum

Is this the equivalent of a ball and socket knee joint

 This is an Xray of a 53 year old lady with history of septic arthritis when 15 years of age send for opinion by a good friend of mine.

This is the closet to a ball and socket knee joint. The only similar case I did was a 83 year old lady from Delhi wherein we did a Link  RHK( Pic below).  The preop pics was with valgus correction for templatingThere was no endpoint in Varus valgus under anaesthesia and the femur appeared to drop off the tibia. In view of her age we did RHK. Its 3 years now and so far successful

Here the h/o septic arthritis which is hopefully quiscent now. In view of her one could try to use a femoral  metephyseal sleeve TM may be and a Varus valgus contrained knee. AN RHK should be on table in case one tries a VV constained knee.  The baja patella is the next problem if resurfaced put a smaller button superiorly. Any other comments are welcome

3 complex knee cases

 Below are 3 cases  send my fellow orthopods for comments. I have given my opinion and would appreciate  and welcome other contributions for this interesting cases

Case 1- 47 year old lady with pain. Apparently patient refused an arthrodesis

My views on case 1.
As  she is 47  an arthrodesis is the first option in view of the complexity, one may not get the best bearings and position. if insistent,  I would use possible a trabecular metal metaphyseal cone or sleeve with wedges to rebuild the lateral condyle. Tibia is standard wedge and stem.  Patella would be major realignment problem. The BAJA could be corrected  by using a smaller patellar button  superiorly. We do not have the skyline view to comment


The answer to bonegrafting question would be if at all it should be an entire distal femoral allograft shaped with a conical proximal( Red Triangle) end jammed into the  host metaphysis and protected with a by pass long stem( green line) as simple lateral condyle reconstruction alone is prone to resorption in the  short to medium term. Even the method I described from elsewhere is prone to fractures and resorption in the medium term. You could argue that one wants to rebulit the bone.

I have one case where in I used the sculpted femoral head( no cartilage) from amrita bone bank to rebuild the lateral condyle in a trauma(bone loss) situation. after  6 months non wt bearing  i did an arthroscopic arthrolysis and got 90 degree ROM. Tthinking about future TKR as the condyle appears vascurised on xray.  No TKR as of yet as least to my knowledge.


Below is vijays postop xray and comments ,
I used femoral metaphyseal cones and L wedges to build up the defect. Th Quadriceps was atrophic and patella was on the lateral gutter. Could mobilize by lateral release . Post op flexion is 80 now. Active extension is very weak.






Kindly opine

 Of course we need better xrays to comment on alignment. He had a RHK back up incase. The metaphyseal cone gave him a stable paltform for the femur to build on.o

Case 2 .A case of 71 yr old female having bilateral FFD of 40 degrees

 On the Lt knee in case 2  One  needs  to be careful of the MCL which,  if incompetent would need a Rotating hinge back up. I  feels if MCL is intact  I would do  try a primary knee or CCK with wedge and stem back up. Stems even if no wedges in view of the porosis and start PTH. 
At 71 RHK is techinically less demanding.

 I think the Rt side  should be standard with  just wedges and stem for tibia and a lateral femoral wedge at best. Watch out for intraop fractures and ligamentous avulsions

.Please send me the post op pics too  if possible for  all of us
 Dr mahajan comments
On Right side - I will use medial tibial wedge & for lateral femoral condyle I will use distal & posterior wedge.I will need tibial as well as femoral stems.

 The postop pics  look fine. The  rt femur is extended . It might be a stress riser if he falls. I would have stemmed  the femur too. Consider PTH injections to build bone too








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