26 years post conservatively treated acetabular fracture with pain and Limp

•  Used Patients femoral head with a reverse  L cut to fill the posterior wall defect and a uncemented THR was done in 2002. the xrays below are at 18 years with no symptoms but superior linear wer is an issue and has to be followed up closely. The AML stem metal head 22 mm head with standard poly was the only available solution in 2002 in india. one had to push hard on  JNJ to bring in larger ceramic bearings  those days

 CT and Xray taken 19 years later with no symptoms. shows  predictable superior wear  with no periprosthetic lysis. the older standard polyethylene and 22.5 modular head in a very active gentleman

Painful flail lt knee post PPRP in 52 year old

52 yr old lad PPRP  had THR  rt side due to pain in a dysplastic hip 8 yrs back. followed by periprosthetic fracture 2 yeasr post op. Nov presents with pain lt knee at rest worse on wlking. cannot tolerate pain any more in the lt flail knee.  Attempted bracing to prevent the 30 degree hyperextension with no relief. Hence an RHK was done to eliminate pain and improve her gait secondarily.  In a flail limb do we do a rotaing hinge or simple hinge. the literature is a bit grey. we need a 5 degree recurvatum with a further stop ideally. We improved her gait and relieved pain for now with a link RHK with recurvatum stop

 

THR in a posterior wall fracture with damaged head

medialise the cup and got primary UN cemented cup and THR

 

HIP REPALCEMENTIN FRESH ANTERIOR COLUMN FRACTURE

 84 YR OLD ACTIVE LADY WITH AN ACUTE ANTERIOR COLUMN FRACTURE

 a ganz cage with host bone conatct and dome screws and cemented THR done to immediately mobilise the elderly and get her home without issues ASAP

Stiff Painfull knee post trauma

50 year old photographer  with a painful stiff knee 11 year post conservative treated femoral fracture

Options of fusion/ replacement with inherent risk of failure/infection and non union was discussed.  Did not expect this avulsion fracture of patella and tibial

TTO was part of exposure to correct the patella Baja

Had a delayed wound healing issues

 

12 years later walking with 0 to 70 degrees flexion. walking full wt bearing with no pain

 

56  yr old lady with stiff knee post patellectomy 20 year ago for an infected patelar fracture  post fixation presented with fracture proximal tibia with bi compartmental arthritis. no infection. Normal ESR/ CRP and normal scar  works as a govt employee living in a women’s hostel and need to climb into a bus

Problems

(pre fracture ROM 10 to 30), 

porotic bone

 ? bugs

financially challenged

 Options

 1. Fixation first with or without cultures

     and second stage tkr

 2 one stage Arthrolysis,Replacement and fixation  

sequence of surgery

 Mid line incision perpendicular to previous transverse incision

 Supra patellar  and gutter scar release. 

 Distal femoral standard resection. cruciate ligaments removed to get tibial intra
medullary access

 Intra medullary tibial jig for  tibial  resection.

 Stemmed tibia to bypass fracture and augmentation with a l medial MIPO tibial plate. graft the   Fracture site with cancelous graft from cut  surface. immediate passive flexion tom 90 obtained  

 and NWB ROM  for 4 weeks

3 months postop

 

Slope correction for acl re-tear prevention

Much has been said about slope correcting osteotomies in ACL injury with > 10 degree tibial slope. Surek et al have found the lateral tibial slope followed by medial tibial slope and lastly differential slope ratio to be statistically significant risk factor for failure.  Therefore correcting  both condyle slope may not be be ideal. Do we need to do selective uni-condyle slope correction to correct the torsional and sagital forces on the reconstructed ACL.

Another biological solution to buy time

 Stromal vascular fraction

Adipose derived stem cell has been used for some time in Plastic surgery and Orthopedics. Its use in joint preservation is increased due to its beneficial effects and to delay or ? avoid knee replacement.  Chondro-protective effects such as chondrocyte proliferation and cartilage matrix protection due to its paracrine actions have been proved in murine models for over a decade

Y.G Koh (KSSTA 2013), on second-look arthroscopy, 87.5 % of elderly patients (14/16) improved or maintained cartilage status at least 2 years post-operatively. No one underwent total knee arthroplasty during this 2-year period.  J. Pak, Int J Mol Sci. 2018 Jul; 19(7):  were among the first to report  injection of adipose derived stem cell as a single harvest and implantation as a medical procedure where are others lab cultured the cells and implanted higher  quantity to as a pharmaceutical product.

 We have been using the same SVF  for close to an year with good functional improvement in young arthritic patients or patients who wants to  avoid or delay knee replacement. In india, at present  cultured adipocyte are not permitted  and  we harvest stems from 60 cc of liposuction, centrifuges as per standard recommendations  and mix with PRP to inject into the knees.